Ocular non-Hodgkin's lymphoma: a clinical study of nine cases

Advanced OCT Analysis of Biopsy-proven Vitreoretinal Lymphoma

PURPOSE

Although diagnosing vitreoretinal lymphoma (VRL) can be challenging, early detection is critical for visual prognosis. We analyzed the spectrum of optical coherence tomography (OCT) findings in patients with biopsy-proven VRL and correlate these features with clinical parameters.

DESIGN

This retrospective cross-sectional study was a multicenter chart review from 13 retina, uveitis, and ocular oncology clinics worldwide from 2008 to 2019. We included patients with a diagnosis of biopsy-proven VRL imaged with OCT at presentation. Ocular information, systemic information, and multimodal retinal imaging findings were collected and studied. The main outcome measure was the characteristics of VRL on OCT.

RESULTS

A total of 182 eyes of 115 patients (63 women, mean age 65 years) were included in this study. The disease was bilateral in 81 patients (70%), and mean baseline visual acuity was 0.2 ± 0.89 logMAR (Snellen equivalent, 20/32). At baseline, 38 patients (33%) presented with isolated ocular involvement, 54 (45%) with associated central nervous system involvement, and 11 (10%) with other systemic lymphomatous involvement; an additional 12 patients (10%) presented with central nervous system and other systemic involvement. On OCT, tumor infiltration was identified in various retinal layers, including lesions in the subretinal pigment epithelium compartment (91% of eyes), the subretinal compartment (43% of eyes), and the intraretinal compartment (7% of eyes). OCT analysis of eyes with VRL identified 3 main regions of retinal infiltration. Subretinal pigment epithelium location, with or without subretinal infiltration, was the most common pattern of involvement and isolated intraretinal infiltration was the least.

Deep learning models for benign and malign ocular tumor growth estimation

Relatively abundant availability of medical imaging data has provided significant support in the development and testing of Neural Network based image processing methods. Clinicians often face issues in selecting suitable image processing algorithm for medical imaging data. A strategy for the selection of a proper model is presented here. The training data set comprises optical coherence tomography (OCT) and angiography (OCT-A) images of 50 mice eyes with more than 100 days follow-up. The data contains images from treated and untreated mouse eyes. Four deep learning variants are tested for automatic (a) differentiation of tumor region with healthy retinal layer and (b) segmentation of 3D ocular tumor volumes. Exhaustive sensitivity analysis of deep learning models is performed with respect to the number of training and testing images using eight performance indices to study accuracy, reliability/reproducibility, and speed. U-net with UVgg16 is best for malign tumor data set with treatment (having considerable variation) and U-net with Inception backbone for benign tumor data (with minor variation). Loss value and root mean square error (R.M.S.E.) are found most and least sensitive performance indices, respectively. The performance (via indices) is found to be exponentially improving regarding a number of training images. The segmented OCT-Angiography data shows that neovascularization drives the tumor volume. Image analysis shows that photodynamic imaging-assisted tumor treatment protocol is transforming an aggressively growing tumor into a cyst. An empirical expression is obtained to help medical professionals choose a particular model given the number of images and types of characteristics. We recommend that the presented exercise should be taken as standard practice before employing a particular deep learning model for biomedical image analysis.

Eye involvement in primary central nervous system lymphoma

Primary central nervous system lymphoma (PCNSL) may manifest initially in the eye (termed vitreoretinal lymphoma or VRL) or in non-ocular CNS compartments, or in both. The nature of the onset of PCNSL implies two clinical specialists - ophthalmologists and neuro-oncologists - independently may assess the primary presentation of this rare malignancy. Clinically relevant perspectives on expectations of PCNSL manifestation in both ocular and non-ocular CNS compartments would help inform management practices in each specialty, which should impact clinical outcomes. A recent increase in the number of published PCNSL cohort studies provides new opportunity to review the current prevalence rates of ocular involvement, and the timing of this involvement over the course of disease. In PCNSL cohorts defined by non-ocular CNS compartment involvement, with or without ocular involvement (termed "PCNSL ± ocular involvement" cohorts), mean rates of concomitant VRL at diagnosis, or at any time during the course, are 10% and 16%, respectively. Only a few individuals within this cohort group present with exclusive eye disease (<5%), and the rate of secondary ocular involvement is only 5-9%. In PCNSL cohorts defined by the involvement of the ocular compartment, with or without non-ocular CNS involvement (termed "VRL ± non-ocular CNS involvement" cohorts), 58% of persons have a primary ocular diagnosis, which carries a 50% risk of secondary involvement in the CNS beyond the eye. Rates of non-ocular CNS involvement with VRL at diagnosis or over the course of disease are 41% and 69%, respectively.

Associations of Systemic Diseases with Intermediate Uveitis

PURPOSE

To determine the associations of systemic diseases with intermediate uveitis.

METHODS

The medical records of 50 consecutive cases with intermediate uveitis referred to The Eye Center in Riyadh, Saudi Arabia, were reviewed. Age- and sex-matched patients without uveitis served as controls. Patients had complete ophthalmic and medical examinations.

RESULTS

There were 27 male and 23 female patients. Mean age was 29 years with a range of 5-62 years. Overall, 21 cases (42%) had systemic disorders associated with intermediate uveitis and 29 cases (58%) had no associated systemic disease. A total of 11 patients (22%) had asthma, 4 (8%) had multiple sclerosis, 3 (6%) had presumed ocular tuberculosis, 1 (2%) had inflammatory bowel disease, 1 (2%) had non-Hodgkin lymphoma and 1 (2%) had sarcoidosis. Evidence of systemic disease was found in 50 (5%) of the 1,000 control subjects. Bronchial asthma was found in 37 patients (3.7 %), multiple sclerosis in 9 patients (0.9%), inflammatory bowel disease in 3 patients (0.3%), and tuberculosis in 1 patient (0.1%). None of the control patients had sarcoidosis or lymphoma. There were statistically significant associations between intermediate uveitis and bronchial asthma (p = 0.0001), multiple sclerosis (p = 0.003) and tuberculosis (p = 0.0005).

CONCLUSION

Bronchial asthma and multiple sclerosis were the most frequently encountered systemic diseases associated with intermediate uveitis in our patient population. Patients with intermediate uveitis should undergo careful history-taking and investigations to rule out associated systemic illness.

Paraneoplastic cloudy vitelliform submaculopathy in primary vitreoretinal lymphoma

PURPOSE

To describe the nature and evolution of paraneoplastic cloudy vitelliform submaculopathy in patients with primary vitreoretinal lymphoma and propose a mechanism for its development and course.

DESIGN

Retrospective, observational case series.

METHODS

Three patients presenting with unilateral cloudy vitelliform submaculopathy based on clinical examination, fundus autofluorescence, fluorescein angiography, and spectral-domain optical coherence tomography (SD OCT) imaging and ultimately diagnosed with primary vitreoretinal lymphoma and/or primary central nervous system lymphoma were analyzed.

RESULTS

In all 3 patients, cloudy vitelliform submaculopathy appeared with hazy indistinct yellow subretinal material resembling the vitelliform lesions found in acute exudative paraneoplastic polymorphous vitelliform maculopathy, although with less distinct appearance and without intense hyper-autofluorescence. In all 3 patients, cloudy vitelliform submaculopathy was transient, showed spontaneous regression within 3 months, and preceded the diagnosis of lymphoma, suggestive of a paraneoplastic process. The diagnosis of primary vitreoretinal lymphoma and/or primary central nervous system lymphoma was made within 6 months with classic features of new intraretinal or sub-retinal pigment epithelium infiltration of lymphoma in the peripheral retina (n = 2) and hyperintense lesions on brain magnetic resonance imaging (n = 2). With SD OCT imaging, the cloudy vitelliform subretinal lesions appeared as hyperreflective debris above the retinal pigment epithelium band in all 3 eyes, and were associated with an irregularly thickened and rippled retinal pigment epithelium band in 2 eyes. Resolution of the cloudy submacular lesions resulted in outer retinal atrophic changes in all 3 eyes.

CONCLUSION

Paraneoplastic cloudy vitelliform submaculopathy, a form of lymphoma-associated retinopathy, can precede the diagnosis of primary vitreoretinal lymphoma or primary central nervous system lymphoma and can regress spontaneously, leaving outer retinal abnormalities.

Natural killer/T-cell lymphoma of nasal type with intraocular involvement: case report

PURPOSE

To report an unusual presentation of disseminated, intraocular, extranodal natural killer/T-cell lymphoma, nasal type (NK/T-cell lymphoma), originating from nasal NK/T-cell lymphoma.

METHODS

Case report.

RESULTS

A 63-year-old woman who had been treated with systemic chemotherapy and radiotherapy for NK/T-cell lymphoma in the nasal cavity presented with vitreous haze of the right eye. Despite anti-inflammatory therapy, the right eye showed poor clinical response and received diagnostic vitrectomy. The vitreous opacity resembled a thin sheet, with no sign of subretinal infiltrate or vascular sheathing. The vitreous specimen contained many large, pleomorphic lymphoma cells. The malignant cells were positive for CD3, CD8, and granzyme B. Systemic workups showed no involvement of other organs. A diagnosis of T-cell lymphoma in the vitreous was made; the tumor likely originated from nasal NK/T-cell lymphoma. The patient was treated with intrathecal chemotherapy and intravitreal methotrexate injection. The eye was clinically clear of malignant cells after the injections.

CONCLUSIONS

Vitreous infiltration without uveoretinal involvement can be an unusual manifestation of intraocular NK/T-cell lymphoma. Clinician awareness of possible ocular involvement may assist in the diagnosis of disseminated NK/T-cell lymphoma.

Ocular central nervous system lymphoma mimicking choroidal neovascularization

Two patients evaluated for metamorphopsia were noted to have inferotemporal retinal pigment epithelium elevations formed by a yellowish lesion. Fluorescein angiography showed granular hyperfluorescence with late leakage, which was interpreted as an occult choroidal neovascularization. One patient underwent photodynamic therapy. In both patients, neither vitreous cells nor neurologic manifestations were evident on presentation. Subsequent neurological signs appeared that prompted performance of brain imaging, which confirmed a space-occupying lesion. In both patients, the tumor was proven on histopathologic examination of brain tissue to be central nervous system lymphoma. Awareness of other possible underlying pathologies is warranted in cases of atypical choroidal neovascularization.

Eradication of tumor colonization and invasion by a B cell-specific immunotoxin in a murine model for human primary intraocular lymphoma

Human primary intraocular lymphoma (PIOL) is predominantly a B cell-originated malignant disease with no appropriate animal models and effective therapies available. This study aimed to establish a mouse model to closely mimic human B-cell PIOL and to test the therapeutic potential of a recently developed immunotoxin targeting human B-cell lymphomas. Human B-cell lymphoma cells were intravitreally injected into severe combined immunodeficient mice. The resemblance of this tumor model to human PIOL was examined by fundoscopy, histopathology, immunohistochemistry, and evaluated for molecular markers. The therapeutic effectiveness of immunotoxin HA22 was tested by injecting the drug intravitreally. Results showed that the murine model resembles human PIOL closely. Pathologic examination revealed that the tumor cells initially colonized on the retinal surface, followed by infiltrating through the retinal layers, expanding preferentially in the subretinal space, and eventually penetrating through the retinal pigment epithelium into the choroid. Several putative molecular markers for human PIOL were expressed in vivo in this model. Tumor metastasis into the central nervous system was also observed. A single intravitreal injection of immunotoxin HA22 after the establishment of the PIOL resulted in complete regression of the tumor. This is the first report of a murine model that closely mimics human B-cell PIOL. This model may be a valuable tool in understanding the molecular pathogenesis of human PIOL and for the evaluation of new therapeutic approaches. The results of B cell-specific immunotoxin therapy may have clinical implications in treating human PIOL.

Lymphomas involving the eye and the ocular adnexa

PURPOSE OF REVIEW

This review assesses the current status of the different methods used in screening for diabetic retinopathy. This update is particularly timely because the incidence of diabetes is rising rapidly and the number of patients with vision-threatening diabetic retinopathy is increasing.

RECENT FINDINGS

We evaluate the different methods used and their results in improving the delivery of eye care to patients with diabetic retinopathy. In populations with poor access to ophthalmic care, screening techniques such as the nonmydriatic camera used in offices of primary care physicians may be useful in identifying lesions of diabetic retinopathy requiring treatment. One of the limitations is the lack of dilation and cataract formation, which may result in ungradable photographs. Patients with treatable lesions as well as those with ungradable photographs should be referred for comprehensive ocular examination.

SUMMARY

Screening techniques do not replace the eye examination. Ophthalmologists can play an important role in diabetic care apart from treating eye disease. Counseling can be provided to patients regarding the importance of blood glucose and blood pressure control and may motivate patients to achieve strict glucose and blood pressure control.

High-grade malignant B-cell lymphoma of the retina in a patient with concomitant gastric MALT lymphoma

PURPOSE

To report the unexpected finding of a primary retinal B-cell lymphoma in a patient with previous breast carcinoma and subsequent lymphoma of the stomach.

METHODS

Histopathologic and immunohistochemical findings in the enucleated eye are described in conjunction with clinical features and investigations.

RESULTS

An 80-year-old woman with previous breast cancer presented with moderate loss of vision associated with vitreous opacities, circumpapillary retinal haemorrhages, and attenuated retinal vessels in her left eye. Treatment with systemic steroids and oral immunosuppressive drugs was initiated on suspicion of carcinoma-associated retinopathy. Two years later, the patient was diagnosed with MALT lymphoma of the stomach. Unfortunately, the ocular symptoms did not improve, and the patient developed neovascular glaucoma, for which the eye was eventually enucleated. Histopathology and immunohistochemistry as well as a molecular analysis revealed a primary B-cell lymphoma of the retina.

CONCLUSION

Non-Hodgkin B-cell lymphoma of the retina should be considered as a differential diagnosis in cases of non-specific retinopathies even in the presence of other primary neoplastic co-morbidities.

Bilateral choroidal infiltration from indolent non-Hodgkin's lymphoma: a rapid course with poor prognosis

A 42-year-old-woman, with a 2 year history of non-Hodgkin's lymphoma suffered sudden bilateral visual loss. This unusual patient presented with an unifocal choroidal tumor in the superionasal quadrant in both eyes. Fluorescein angiography revealed early and late intense subretinal fluorescence. Cytological examination of the anterior chamber and vitreous tap material revealed abnormal lymphocytes compatible with NHL. Diffuse choroidal infiltration was diagnosed and treated with radiotherapy. Radiotherapy did not provide local control and preservation of the vision. Non-Hodgkin's lymphoma can infiltrate to the choroid and radiotherapy may not be efffective in every case.

Primary intraocular lymphoma: a review of the clinical, histopathological and molecular biological features

INTRODUCTION

Primary intraocular lymphoma (PIOL) is a rare non-Hodgkin lymphoma which arises in the retina or the vitreous. It can occur either together with or independently of primary cerebral nervous system lymphoma (PCNSL); the incidence of the latter has significantly increased over the past three decades. PIOL remains one of the most difficult diagnoses to establish, particularly due to its ability to mimic other diseases in the eye and to the limited material which is often available for examination.

METHODS

The article reviews the clinical, histopathological, molecular biological and biochemical approaches to the diagnosis of PIOL. The differential diagnoses, including other lymphomatous manifestations in the eye, e.g. primary uveal lymphoma, as well as non-neoplastic uveal diseases are addressed. Furthermore, the treatment strategies for PIOL are summarised.

RESULTS

Diagnostic progress has been made in various fields, including flow cytometry and immunocytology, cytokine analysis, and as well as molecular biological analysis of the immunoglobulin heavy and light chains using polymerase chain reaction on both fixed and non-fixed material. The optimal therapy of PIOL remains to be determined: the current trends suggest that combined radiotherapy and chemotherapy, as well as intravitreal chemotherapy, are of value. Novel therapies which may have a role in the future include oral trofosfamide.

CONCLUSION

Our understanding of the pathogenesis of PIOL/PCNSL remains far from complete. Intensified efforts must be made to determine the cell of origin of PIOL, as well as to establish "molecular signatures", which could be used to decrease diagnostic delay. Further studies, possibly prospective ones, are required to establish the optimal therapy for initial and recurrent disease.

Evaluation of vitrectomy specimens and chorioretinal biopsies in the diagnosis of primary intraocular lymphoma in patients with Masquerade syndrome

PURPOSE

To correlate the histopathological diagnoses established by diagnostic vitrectomy and chorioretinal biopsy in patients with clinically suspected primary intraocular lymphoma (PIOL) or chronic idiopathic uveitis, and the clinical follow-up data.

METHODS

Eighty-four consecutive pars plana vitrectomy (PPV) specimens, three chorioretinal biopsies and two enucleated eyes taken from 80 patients were evaluated. All PPV specimens were unfixed; these were centrifuged, the "cytospins" being stained conventionally (May-Grünwald-Giemsa) and using immunocytology (CD79a, CD3, CD68, immunoglobulin (Ig) light chains). An extended immunohistochemical panel, as well as polymerase chain reaction (PCR) for rearrangements of the Ig heavy chain gene (IgH-PCR), were used to investigate the chorioretinal biopsies and the enucleated eyes. Diagnoses, made on the basis of morphology and immunophenotype, included "reactive cellular infiltrate", "malignant lymphoma", "suspicious of neoplastic disease", and "insufficient for diagnosis". The corresponding clinical data were collected and compared with the diagnosis.

RESULTS

The 80 patients consisted of 46 women and 34 men. The patients' age range varied from 21 to 100 years (mean age 62 years). Sixty-two (74%) of the 84 vitrectomy specimens were diagnosed as "reactive cellular infiltrate", 12 (14%) as definite "malignant lymphoma", 5 (6%) as "suspicious of neoplastic disease" and 5 (6%) specimens were considered "insufficient for diagnosis". An additional chorioretinal biopsy enabled an unequivocal diagnosis of PIOL to be reached in 3 patients. All PIOL were diffuse large cell B-cell lymphoma (DLBCL), with the immunophenotype CD79+, CD20+, BCL-2+, BCL-6+, MUM1+ and monotypical expression for IgM+. A monoclonal IgH-PCR amplification product was obtained in four vitrectomy specimens, two chorioretinal biopsies and one of the enucleated eyes. Comparison of the diagnoses with long-term follow-up clinical data resulted in concordance in 77 (96%) cases and discrepancies ("false-negative" diagnoses) in 3 patients (4%). The patients diagnosed with lymphoma were treated with either radiotherapy, chemotherapy or both. At final follow-up (mean 35 months), 5 patients (6%) had developed cerebral lymphomatous manifestation, and 7 (9%) had succumbed to their disease.

CONCLUSION

The diagnosis of PIOL is often extremely difficult, requiring sufficient rapidly transported good-quality material, and experienced interpretation. Although cytological examination of vitreal aspirates remains the gold standard in diagnosis, examination of chorioretinal biopsies increase the reliability of diagnosing or excluding a PIOL that involves the retina or choroid. Most PIOL are DLBCL with an immunophenotype suggesting a cellular origin from germinal centre cells.

Diagnostic yield of vitrectomy in eyes with suspected posterior segment infection or malignancy

PURPOSE

To determine the yield of diagnostic pars plana vitrectomy in eyes with suspected posterior segment inflammation or malignancy when clinical examination and systemic laboratory testing did not yield a specific diagnosis.

DESIGN

Non-comparative interventional case series

PARTICIPANTS

Eighty-seven consecutive patients (90 eyes) who underwent diagnostic pars plana vitrectomy from 1989 through 1999.

INTERVENTIONS

Vitreous samples were analyzed in a directed manner based on the preoperative clinical examination and systemic laboratory testing.

MAIN OUTCOME MEASURES

Diagnosis from each test performed on the vitreous samples.

RESULTS

Diagnostic vitrectomy was performed alone in 6 eyes (7%) and as part of a therapeutic procedure in the remaining 84 eyes. The diagnostic tests performed most frequently included cytopathology (83%), microbiologic culture and sensitivity (43%), polymerase chain reaction (PCR) (36%), and intraocular antibody levels for T. canis (14%). Of these, intraocular antibody testing and PCR had the highest positive yield, 46% and 39%, respectively. Overall, directed vitreous analysis identified a specific cause in 35 eyes (39%). Of the 65 cases in which an underlying infection was suspected preoperatively, the procedure yielded a specific diagnosis in 27 (42%). When intraocular malignancy was considered preoperatively (71 eyes), a diagnosis of intraocular lymphoma was obtained in seven (10%). This difference between these diagnostic yields was significant (P = 0.02, Fisher's exact test).

CONCLUSIONS

Diagnostic vitrectomy with directed vitreous fluid analysis yields a specific cause and guides subsequent therapy in a high percentage of cases. This procedure is a valuable adjunct in cases that cannot be diagnosed by less invasive methods.

Neoplastic masquerade syndromes

Masquerade syndromes are classically defined as entities which emulate inflammatory conditions but which are in fact due to a neoplastic process. Careful history and examination in concert with appropriate ancillary investigations and histopathologic evaluation of tissue specimens are required in order to make the correct diagnosis. Many conditions may result in an appearance mimicking an inflammatory condition. The authors review neoplastic conditions which may be considered masquerades. The most common of these is primary intraocular lymphoma or primary central nervous system lymphoma, occurring predominately in older individuals. Diagnostic strategies, therapy, and prognosis are reviewed in detail. Other conditions that can be considered masquerade syndromes are reviewed as well, including lymphomatous and nonlymphomatous conditions, such as melanoma, retinoblastoma, juvenile xanthogranuloma, metastatic lesions, and paraneoplastic syndromes, among others.

Angiocentric T-cell lymphoma of the pancreas presenting as late-onset diabetes mellitus with diabetic retinopathy

Pancreatic lymphoma presenting with clinical diabetes mellitus (DM) is rare. We report angiocentric T-cell lymphoma of the pancreas in a 65-year-old Thai woman who presented with progressive deterioration of visual acuity of both eyes. She had diabetic retinopathy (DR) diagnosed only 20 months after the diagnosis of DM at the age of 63. She later developed erythematous rashes, fever, and deterioration of consciousness; she eventually died of shock. A skin biopsy and bone marrow examination revealed angiocentric T-cell lymphoma. At autopsy, the pancreas and both eyes were extensively infiltrated by lymphoma. Widespread involvement of nearly all organs but superficial lymphadenopathy was detected. In contrast to other typical cases of long-standing DM, only mild atherosclerosis was noted, and no DR was found. To the best of our knowledge, this is the first case of lymphoma involving the pancreas and both eyes producing clinical DM and DR.

Therapeutic management of primary central nervous system lymphoma: lessons from prospective trials

Primary central nervous system lymphomas (PCNSL) are aggressive malignancies, exhibiting one of the worst prognoses among lymphomas. The best treatment modality for PCNSL has not yet been identified. Several therapeutic questions still remain unanswered, and some methodological pitfalls in clinical trials prevent definitive conclusions from being drawn. In this review, certain aspects of trial design as well as emerging therapeutic guidelines are analyzed, and future perspectives are discussed. In the vast majority of prospective trials, general criteria for treatment of aggressive lymphomas were adopted, choosing primary chemotherapy (CHT) followed by radiotherapy (RT) as therapeutic modality. This strategy produced a five-year survival of 22%- 40% in comparison to the 3%-26% reported with RT alone. Systemic high-dose methotrexate (HD-MTX) seems to be the most effective drug, producing a response rate of 80%-90% and a two-year survival of 60%-65%. To date, the addition of other drugs at conventional doses have not consistently improved outcome. With a few exceptions, any regimen without HD-MTX comprehensively performed no better than RT alone. In combined treatment. RT doses should be decided on the bases of response to primary CHT and the number of lesions, and, until definitive conclusions from well-designed trials are available, RT parameters should follow the widely accepted principles used for other aggressive lymphomas. CHT as exclusive treatment, keeping RT for relapses or persistent disease, appears to be an attractive strategy. However, the worldwide experience with this modality is still limited, and corroborating data are needed. Intrathecal CHT still has not found a defined role in PCNSL management. Preliminary data seem to indicate that adequate meningeal treatment with HD-MTX, but without intrathecal CHT, could also be suitable in positive-cerebrospinal fluid patients. Future efforts should be addressed to identify new active drugs and more efficient CHT combinations, to evaluate the efficacy of high-dose CHT supported by autologous peripheral blood stem cells transplantation, and to clarify the impact of RT delay in complete responders, the usefulness of intrathecal CHT, and the best management for elderly patients. The assessment of impact of treatment on neuropsychological functions and quality of life is a mandatory endpoint in clinical trials.

Toxoplasmosis in a patient with non-Hodgkin's lymphoma: the need for a good differential diagnosis

Toxoplasma gondii is an obligate intracellular parasite responsible for toxoplasmosis. Congenital and acquired forms of the disease have now been reported. In immunocompromised patients, the disease entity may resemble other diseases. Presented for discussion is an interesting case of acquired toxoplasmosis in an immunocompromised patient with several confounding factors necessitating a good differential diagnosis list. Also provided is a comprehensive review of toxoplasmosis diagnosis and management.