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Panuvieits in an elderly patient
First Author: S. Neary IRELAND
Co Author(s): I. Tuwir
Toxoplasma gondii is the most common cause of infectious posterior uveitis worldwide in immunocompetent patients. Despite its prevalence, diagnosis can still be challenging and delayed diagnosis may be vision-threatening in severe presentations. This case highlights the importance of a thorough history, clinical exam and additional workup in diagnosing cases with atypical presentation.
A 85-year-old lady presented with a one month history of left floaters and blurred vision. Her past ophthalmic history included right pseudophakia and right pseudoexfoliation glaucoma on taptiqom nocte OD. Her general medical health was good apart from polymyalgia rheumatica on 4mg oral prednisolone. Exam was as follows: vision 6/20 OD, 6/36 OS, IOP 20 OD and 32 OS. The right eye was quiet with a PCIOL and fundal exam was normal. The left eye had mutton fat keratitic precipitates, mild anterior chamber inflammation, and moderate nuclear scleroris. There was dense vitritis and a superior macular fluffy yellowish retinal lesion.
Topical azopt was added to taptiqom for IOP control. A full blood work up was ordered. A chest x-ray was normal. Syphilis serology and QuantiFERON-TB Gold were negative. Toxoplasma gondii IgM was positive. On further questioning, the lady admitted to keeping two wild cats as pets. She was commenced on oral azithromycin and a reducing dose of concomitant oral prednisolone.
One-third of the world's human population is infected by Toxoplasma gondii. Serum IgM titre has a sensitivity of 99.4% and a specificity of 49.2%. Serum IgG titre sensitivity and specificity varies depending on the threshold limit used for diagnosis. Ocular serology via GWC testing has a reported sensitivity of 93% and specificity of 100% and ocular fluid PCR sensitivity ranges from 30% to 67%, while specificity is 100%. Ocular toxoplasmosis has long been regarded as mainly a congenital infection, however this was challenged by a Brazilian study demonstrating that postnatal infection and ocular manifestations of toxoplasmosis were more common.
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