Immune recovery vitritis in an HIV patient with isolated toxoplasmic retinochoroiditis

Ocular toxoplasmosis, an overview focusing on clinical aspects

Toxoplasma gondii is a widespread protozoan parasite infecting approximately one third of the world population. After proliferation of tachyzoites during the acute stage, the parasite forms tissue cysts in various anatomical sites and establishes chronic infection. Nowadays the nature of the interplay between the protozoan and its human host remains elusive. This is clearly evident in ocular toxoplasmosis, in which the parasite establishes an ambivalent relationship with the eye, manipulating the immune response and inducing variable initial lesions and further relapses. This review will focus on epidemiology and environmental, parasite and host related risk factors, clinical manifestations and laboratory findings, treatment and prophylaxis approaches in ocular toxoplasmosis. An image collection of patients referred to the Unit of Ophthalmology of Pisa's Hospital will be presented, too.

Disease of the Year 2019: Ocular Toxoplasmosis in HIV-infected Patients

Ocular toxoplasmosis (OT) may be an initial manifestation of acquired immunodeficiency syndrome (AIDS) in human immunodeficiency virus (HIV)-infected patients. OT has different clinical manifestations and can mimic other intraocular infections. Clinical findings may show single or multifocal retinochoroidal lesions or panuveitis. Atypical presentations are associated with extensive uni- or bilateral areas of retinal necrosis. OT lesions not associated with preexisting retinochoroidal scars are usually due to acquired rather than congenital infection. When CD4+ T cell counts are <100 c/uL, vitritis is frequently mild. Isolated anterior uveitis has been reported in single cases. Positive immunoglobulin M (IgM) antibodies are rare but their presence can support the diagnosis. As atypical presentations of OT are common, anterior chamber puncture for multiplex polymerase chain reaction amplification of infectious DNA should be considered, as early diagnosis and treatment can prevent massive tissue destruction and preserve vision. This review provides an overview of OT in HIV-infected patients.

Immune-recovery posterior uveitis associated with inactive isolated toxoplasmic retinochoroiditis in a patient with human immunodeficiency virus

PURPOSE

To report a case of severe panuveitis in a patient with human immunodeficiency virus that developed after inactivation of toxoplasmic retinochoroiditis. The patient also developed cerebral toxoplasmosis.

METHODS

A patient with human immunodeficiency virus who developed immune-recovery posterior uveitis in the context of inactive toxoplasmic retinochoroiditis underwent complete ophthalmologic evaluation, polymerase chain reaction of the aqueous humor, diagnostic vitrectomy, and cerebral ancillary testing.

RESULTS

Polymerase chain reaction-confirmed toxoplasmic retinochoroiditis healed with appropriate treatment, but 2 months later coinciding with systemic immune restoration, the brain lesions worsened and immune-recovery panuveitis caused decreased visual acuity. Diagnostic vitrectomy confirmed only inflammatory cells.

CONCLUSION

Immune-recovery panuveitis caused by cytomegalovirus retinitis is well documented, but we found only one published case caused by toxoplasma. Immune-recovery panuveitis should not be ruled out despite the absence of previous cytomegalovirus retinitis. A patient with human immunodeficiency virus who has had an intraocular opportunistic infection, despite resolution, must be followed-up by an ophthalmologist in collaboration with an infectious disease specialist to prevent blindness.

Parasitic infections in HIV infected individuals: diagnostic & therapeutic challenges

After 30 years of the human immunodeficiency virus (HIV) epidemic, parasites have been one of the most common opportunistic infections (OIs) and one of the most frequent causes of morbidity and mortality associated with HIV-infected patients. Due to severe immunosuppression, enteric parasitic pathogens in general are emerging and are OIs capable of causing diarrhoeal disease associated with HIV. Of these, Cryptosporidium parvum and Isospora belli are the two most common intestinal protozoan parasites and pose a public health problem in acquired immunodeficiency syndrome (AIDS) patients. These are the only two enteric protozoan parasites that remain in the case definition of AIDS till today. Leishmaniasis, strongyloidiasis and toxoplasmosis are the three main opportunistic causes of systemic involvements reported in HIV-infected patients. Of these, toxoplasmosis is the most important parasitic infection associated with the central nervous system. Due to its complexity in nature, toxoplasmosis is the only parasitic disease capable of not only causing focal but also disseminated forms and it has been included in AIDS-defining illnesses (ADI) ever since. With the introduction of highly active anti-retroviral therapy (HAART), cryptosporidiosis, leishmaniasis, schistosomiasis, strongyloidiasis, and toxoplasmosis are among parasitic diseases reported in association with immune reconstitution inflammatory syndrome (IRIS). This review addresses various aspects of parasitic infections in term of clinical, diagnostic and therapeutic challenges associated with HIV-infection.

Immune recovery uveitis associated with highly active antiretroviral therapy in a patient with CMV retinitis and AIDS despite a low CD4+ T cell count: case report and a review of the literature

An unusual case of CMV retinitis and AIDS who developed immune recovery uveitis (IRU) despite a low CD4+ T cell count achieved during HAART is reported. A 36-year-old female complained of blurred vision in both eyes six months after initiation of anti-CMV retinitis therapy and HAART. Ocular examination revealed a substantial intraocular inflammation causing a dense vitreous haze and frosted branch angiitis. Consecutive CD4+ T cell counts were 20 cells/mm(3) or less and plasma HIV mRNA was undetectable. The laboratory test for Cytomegalovirus was positive whereas those for infections known to cause uveitis were negative. The inflammatory reaction resolved with treatment, but she developed retinal detachment just before she died of pulmonary complications. A review of the literature led us to propose that our patient developed an intraocular inflammation which may probably be a form of IRU and it might be appropriate to employ additional criteria in the definition and the diagnosis of IRU.