Serpiginous choroidopathy: an unusual association with Crohn's disease

Tubercular serpiginous choroiditis

Tubercular association with serpiginous choroiditis, also called ‘serpiginous-like choroiditis’ or ‘multifocal serpiginoid choroiditis’ (MSC) is reported from world over, especially from endemic countries. Though the exact mechanism is not yet clear, a direct or indirect infectious trigger by Mycobacterium tuberculosis (MTB) is believed to cause choroiditis.

The link of immune mechanisms with ocular inflammation caused by MTB is emerging, and has been supported by both experimental and human data. The molecular and histopathological findings of tubercular serpiginous-like choroiditis have been demonstrated in clinicopathological reports, as well as in animal models. Young to middle-aged healthy males are more frequently affected. The choroiditis lesions of tubercular serpiginous-like choroiditis evolve as multifocal lesions, affecting the retinal periphery as well as posterior pole. They begin as discrete lesions, and spread in a serpiginoid pattern to become confluent. Fundus imaging including autofluorescence is extremely helpful in monitoring patients for response to therapy. Its diagnosis is essentially clinical. Corroborative evidence is obtained by a positive tuberculin skin test, or a positive QuantiFERON-TB Gold (Cellestis, Carnegie, Victoria, Australia) test, and/or radiological (chest X-ray or chest CT scan) evidence of TB elsewhere in the body. Systemic corticosteroids are the mainstay of therapy to control active inflammation, while ATT helps to reduce recurrence of inflammatory attacks. Immunosuppressive agents are indicated in cases with relentless progression, paradoxical worsening, or recurrent choroiditis.

Serpiginous Choroiditis Presenting in Association With Clostridium difficile Infection and Ulcerative Colitis

Purpose:

This work reports a case of serpiginous choroiditis (SC) in association with ulcerative colitis and Clostridium difficile infection.

Methods:

A case report is discussed.

Results:

A 35-year-old man with a history of ulcerative colitis and recently treated C difficile infection presented with a rapid decline in central visual acuity in both eyes. Examination findings included geographic creamy-white lesions extending from the peripapillary region in both eyes. Multimodal imaging and negative infectious workup results supported the diagnosis of SC. Visual acuity and examination findings improved after initiation of systemic prednisone therapy. Adalimumab was initiated as a steroid-sparing treatment. At the last follow-up, 5 months after the initial presentation, SC and ulcerative colitis both remain in remission.

Conclusions:

SC has been previously described in patients with systemic disorders, including autoimmune conditions. This patient developed SC following C difficile infection and in the context of active ulcerative colitis. To our knowledge, this is the first report of SC in association with these entities.

Ophthalmic manifestations in patients with inflammatory bowel disease: A review

Clinical manifestations of inflammatory bowel disease (IBD) are not locally restricted to the gastrointestinal tract, and a significant portion of patients have involvement of other organs and systems. The visual system is one of the most frequently affected, mainly by inflammatory disorders such as episcleritis, uveitis and scleritis. A critical review of available literature concerning ocular involvement in IBD, as it appears in PubMed, was performed. Episcleritis, the most common ocular extraintestinal manifestation (EIM), seems to be more associated with IBD activity when compared with other ocular EIMs. In IBD patients, anterior uveitis has an insidious onset, it is longstanding and bilateral, and not related to the intestinal disease activity. Systemic steroids or immunosuppressants may be necessary in severe ocular inflammation cases, and control of the underlying bowel disease is important to prevent recurrence. Our review revealed that ocular involvement is more prevalent in Crohn's disease than ulcerative colitis, in active IBD, mainly in the presence of other EIMs. The ophthalmic symptoms in IBD are mainly non-specific and their relevance may not be recognized by the clinician; most ophthalmic manifestations are treatable, and resolve without sequel upon prompt treatment. A collaborative clinical care team for management of IBD that includes ophthalmologists is central for improvement of quality care for these patients, and it is also cost-effective.

Serpiginous choroiditis in a referral clinic in India: visual field changes and clinical correlates

PURPOSE

To report the visual field changes in patients with serpiginous choroiditis as seen in a referral clinic in India.

METHODS

A retrospective noncomparative case series was conducted. Twenty-nine eyes of 17 patients who were diagnosed with serpiginous choroiditis were included in the study. Clinical findings were recorded. Visual field was measured with a Humphrey visual field analyzer. Information obtained was entered into SPSS 17.0 and analyzed.

RESULTS

There was a male preponderance (8:2). Age at presentation ranged from 14 to 53 years. Eleven subjects (64.7%) had bilateral involvement at presentation. Mean visual acuity improved to 0.35 after treatment. Visual field changes were seen in 28 eyes and the mean deviation value was maintained after treatment (-8.5, 7.19 SD). Multiple foci of defects (usually central or paracentral scotoma co-existing with isolated field defects in the nasal or temporal field) were the commonest form of visual field defect detected.

CONCLUSION

Patients with serpiginous choroiditis had a stable visual field defects after 6 months of treatment. The need for visual field monitoring in these patients is underscored.

Serpiginous choroiditis and infectious multifocal serpiginoid choroiditis

Serpiginous choroiditis (SC) is a posterior uveitis displaying a geographic pattern of choroiditis, extending from the juxtapapillary choroid and intermittently spreading centrifugally. The choroiditis involves the overlying retinal pigment epithelium, and the outer retina. This intraocular inflammation typically involves both eyes in otherwise healthy, middle-aged individuals with no familial or ethnic predilection. Pathogenesis is unclear; based on limited histopathologic studies, however, favorable response to immunosuppressive agents, and the absence of association with systemic or local infectious or noninfectious diseases, an organ-specific autoimmune inflammation seems likely to be the underlying process. Patients, particularly from tuberculosis-endemic regions, may present with fundus changes simulating SC, but show evidence of active tuberculosis and/or the presence of mycobacterial DNA in the aqueous humor. This has been referred to as serpiginous-like choroiditis, but we prefer the description multifocal serpiginoid choroiditis (MSC). We present the distinguishing features of SC and infectious multifocal serpiginoid choroiditis simulating SC. The distinction is crucial to avoid unnecessarily treating SC with antimicrobial agents. Advances in diagnostic and imaging modalities can help differentiate SC from MSC. Novel local and systemic treatment approaches improve the outcome and preserve vision in SC.

[Choroiditis and Crohn disease: a case report]

INTRODUCTION

Crohn disease is an inflammatory bowel disease. Extradigestive manifestations can occur, especially ocular inflammation, but posterior choroidal inflammation is more unusual.

OBSERVATION

We report the case of a 42-year-old woman, suffering from histologically proven Crohn disease for one year, who developed choroiditis in the left eye of unknown etiology. Fundus and fluorescein angiography displayed an aspect mimicking ampiginous choroiditis, and indocyanine green (ICG) angiography disclosed a large choroidal subtractive aspect.

CONCLUSION

This case is a rare example of posterior segment manifestation in Crohn disease, possibly due to choroidal infiltration by inflammatory cells or choroidal focal ischemia.

Serpiginous Choroiditis

Serpiginous choroiditis is a rare, usually bilateral, chronic, progressive, recurrent inflammation of the choroid, retinal pigment epithelium, and choriocapillaris of unknown etiology. Based on clinical presentation, it can be classified into 1) peripapillary, 2) macular, and 3) ampiginous types. The clinical course, regardless of the presentation, is progressive with multiple recurrences leading to potentially significant visual loss. Visual outcome is directly related to the involvement of the para-fovea and fovea by the lesions or secondary choroidal neovascularization. The histological findings of the lesions are atrophy of the choriocapillaris, retinal pigment epithelium and photoreceptor cells, and moderate diffuse lymphocytic infiltrates throughout the choroid. Multiple etiologies including autoimmunity, infection, vasculopathy, and degeneration were proposed but none is well supported by clinical and laboratory evidence. Fluorescein and indocyanine green angiography have been useful in the assessment of the extent and the activity of lesions. Due to the insidious and progressive clinical course, an assessment of treatment outcomes needs long term follow-up. Currently, treatment with immunosuppressive and alkylating agents have shown possible efficacy in small case series. Larger clinical studies and interventional trials are required to further our understanding of the pathogenesis, etiology, and for the evaluation of treatment strategies.