What the Cat Dragged In?

Strange Things Seen in Practice

Sina Rezaei, BS; Rizwan Shaikh, MD; Christina Y. Weng, MD, MBA

Disclosures

April 23, 2019

Editor's Note:
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A 31-year-old woman with a history of treated latent tuberculosis presented with a 3-week history of painless, progressive blurry vision in her right eye. She denied experiencing any flashes or floaters. She was otherwise healthy and had no history of sexually transmitted diseases or animal exposure. She traveled to Puerto Rico a year ago.

Her best-corrected visual acuity (BCVA) was 20/30 in the right eye and 20/20 in the left eye. Slit-lamp examination findings in both eyes were unremarkable. A dilated fundus examination was performed, with normal findings in the left eye, but the right eye revealed a creamy white lesion along the superotemporal arcade abutting a small pigmented area, localized vasculitis, and 1+ vitreous cell (Figure 1).

Figure 1. Fundus photograph of the right eye. A creamy white lesion along the superotemporal arcade with local vasculitis and focal overlying vitritis can be seen. A small area of pigment was also seen proximal to the active lesion, probably representing the site of a previous infection.

The optic nerve and macula in both eyes were normal.

Optical coherence tomography through the lesion in the right eye demonstrated retinal thickening with inner and outer retinal disorganization, adjacent subretinal fluid, and overlying hyperreflective vitreous opacities (Figure 2).

Figure 2. Optical coherence tomography. Hyperreflectivity and disorganization through all retinal layers (star), adjacent pockets of subretinal fluid (arrows), and overlying hyperreflective vitreous opacities (arrowhead) with an attached thickened posterior hyaloid face are seen.

Serum testing was positive for Toxoplasma gondii immunoglobulin G (IgG) but negative for immunoglobulin M (IgM).

The patient eventually revealed that she had been treated for a similar episode in the past. She was diagnosed with presumed ocular toxoplasmosis and treated with an 8-week course of trimethoprim-sulfamethoxazole (800 mg/160 mg). Oral prednisone was initiated 2 weeks after starting antibiotic therapy. Twelve weeks later, her chorioretinal lesion had evolved into a pigmented scar with no signs of active infection (Figure 3). Her BCVA in the right eye returned to 20/20.

Figure 3. Fundus photograph of the right eye 12 weeks after completion of therapy. A hyperpigmented scar is seen in place of the previous area of retinitis seen at initial presentation.

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