Acute syphilitic posterior placoid chorioretinopathy presenting as atypical multiple evanescent white dot syndrome.

BACKGROUND: This paper reports the case of a young man who presented with syphilis masquerading as multiple evanescent white dots syndrome (MEWDS), which turned out to be an acute syphilitic posterior placoid chorioretinopathy (ASPPC) during follow-up. CASE PRESENTATION: A 59-year-old healthy male consulted for a three days' history of visual impairment in both eyes. On multimodal imaging, he was diagnosed as MEWDS. Fundus fluorescein angiography (FFA) showed early peripheral bilateral granular hyperfluorescence that correlated with the yellow-white dots found on fundus exam. Indocyanine green angiography (ICGA) depicted hypofluorescent dots on late phase. Spectral-domain optical coherence tomography (SD-OCT) revealed numerous inner retinal highly reflective deposits in the outer nuclear layer and disruption of the ellipsoid zone. After initial improvement, he presented again for a sudden visual loss at 3 weeks. FFA, ICGA and SD-OCT demonstrated the same but more numerous and outer lesions suggesting an ASPPC. A full inflammatory work-up revealed highly positive titers of rapid plasma regain (RPR) and fluorescent treponemal antibody absorption (FTA-Abs), suggesting a syphilis infection. The ophthalmological manifestations dramatically improved after the patient was admitted for high-dose intravenous penicillin G 24 million per day for 2 weeks. CONCLUSION: This is the first case that reports an ocular syphilitic infection masquerading as MEWDS at presentation and that turns to be an ASPPC. Syphilis serology should be routinely done in every case of atypical MEWDS especially when unusually presented in a young healthy man, with bilateral involvement and a bad clinical evolution.

Adjunctive bradyzoite-directed therapy for reducing complications of congenital toxoplasmosis.

Congenital toxoplasmosis is caused by in utero infection of the fetus with the intracellular parasite Toxoplasma gondii. Upon infection, the parasite forms life-long cysts in fetal brain and eyes which are resistant to the currently accepted therapy of pyrimethamine and sulfadiazine. These cysts commonly reactivate later in life causing chorioretinitis and visual impairment, and rarely cause neurological complications. I hypothesize that adjunctive, bradyzoite-directed therapies have the potential to alleviate a significant burden of disease by reducing cyst burden in neonatal brain and eyes. Atovaquone is perhaps the most promising drug for further evaluation given its low side-effect profile, established safety, and efficacy in animal models reducing cyst burden. Very limited observational data in humans suggests atovaquone may prevent Toxoplasma-associated chorioretinitis recurrence. Clinical trials are needed to evaluate it and other potential drugs as adjunctive treatment in congenital toxoplasmosis.

Intravitreal Injection of Sulfamethoxazole and Trimethoprim Associated with Dexamethasone as an Alternative Therapy for Ocular Toxoplasmosis.

PURPOSE: To evaluate intravitreal injections of sulfamethoxazole/trimethoprim in association with dexamethasone for treating toxoplasmic retinochoroiditis. METHODS: Thirteen patients with active, recurrent ocular focal toxoplasmic retinochoroiditis and visual acuity worse than 20/63 in the affected eye were included. Ocular toxoplasmosis was diagnosed according to the classic clinical findings. The primary end point was the change in the final best-corrected visual acuity (BCVA). RESULTS: The intraocular inflammation decreased within 2 weeks after injection in all eyes and resolved in 8 (62%) eyes with only one injection after 30 days; the remaining eyes received two injections. In all eyes, the retinitis was inactive and no patient had decreased early treatment diabetic retinopathy study lines of BCVA at the final examination. CONCLUSION: The combination of intravitreal trimethoprim/sulfamethoxazole and dexamethasone might be an alternative treatment strategy in patients with toxoplasmic retinochoroiditis.

Intravenous Ceftriaxone for Syphilitic Uveitis.

PURPOSE: Report of clinical/multimodal imaging outcomes of patients with syphilitic uveitis alternatively treated with intravenous(IV) ceftriaxone, due to unavailability of penicillin G. METHODS: Chart review of all cases of syphilitic uveitis presenting to Hospital São Geraldo/HC-UFMG and treated with intravenous ceftriaxone, between January and August 2014. Clinical, serological and ophthalmological data were collected. RESULTS: Twelve consecutive patients with syphilitic uveitis receiving IV ceftriaxone were identified. All 24 eyes had active intraocular inflammation on clinical examination. All patients received IV ceftriaxone (2-4 g daily) for 14-21 days, supplemented with oral corticosteroid as needed in 9 patients (75%), after documented clinical response. Improvement in intraocular inflammation was seen in all 24 eyes, with median best-corrected visual acuity (BCVA) increasing from 20/50 to 20/20, after a mean follow-up of 5.3 months. CONCLUSION: IV ceftriaxone may be an effective alternative for treatment of syphilitic uveitis, in the setting of unavailability of penicillin G.

[Dynamic phototherapy as a treatment for central serous chorioretinopathy]. / Traitement des choriorétinopathies séreuses centrales par photothérapie dynamique.

PURPOSE: To analyze the angiographic and tomographic results and the visual acuity of a group of patients presenting acute or chronic serous central chorioretinopathy (CSCR) treated with dynamic phototherapy. This treatment was guided by ICG angiography data. PATIENTS AND METHOD: We conducted a retrospective/prospective nonrandomized study on 31 eyes of 27 patients, including eight acute forms and 23 chronic forms. One or more spots were treated according to the age-related macular degeneration standard protocol on the zones of choroidal hyperpermeability highlighted by ICG angiography. The criteria for success were based on functional signs, visual acuity, persistence of a point of leakage in angiofluorographic follow-up at 3 months, and the OCT study of serous retinal detachment. RESULTS: An increase in visual acuity (3.58+/-3.22 lines, p<0.0001) was observed for all forms of treated CSCR; 90.32% patients presented a reapplication of serous retinal detachment within a period of 7.28+/-3.93 weeks. No retinal pigmentary epithelium tear or choroidal neovascularization was observed. Recurrence occurred in 12.9% patients within a period of 28+/-16.24 weeks; only chronic CSCR cases were concerned. At 8+/-4.2 months, the visual acuity of the patients who had no recurrence remained unchanged (0.356+/-0.4 LogMAR or 20/50-20/40). CONCLUSION: Although the number of patients included in this study is limited, dynamic phototherapy currently seems to be an effective and sure treatment of CRSC. A randomized study on a large series is necessary to confirm these results.

[High-dosage combination antibiotic treatment in severe therapy-resistant uveitis and necrotizing (chorio)retinitis]. / Hochdosierte antibiotische Kombinationsbehandlung bei schweren therapierefraktären Uveitiden und nekrotisierenden (Chorio-) Retinitiden.

Twelve patients with extremely severe uveitis and two patients with necrotizing (chorio-)retinitis were treated with a combination of antibiotics consisting of penicillin G, gentamicin and metronidazole. The antibiotics were administered in 5 cases (all uveitis patients) after unsuccessful long-term treatment with other drugs, in nine cases after short-term treatment with other drugs or immediately. The treatment was effective in 10 of the uveitis patients, including all 5 cases in which the previous treatment had been unsuccessful. In 2 cases it was ineffective. It was effective, however, in both of the cases of necrotizing (chorio-)retinitis. The duration of the required treatment with antibiotics was not significantly prolonged in cases which had previously undergone long-term treatment with other drugs. However, the clinically detectable onset of improvement of vision and of the findings was significantly delayed. Despite some cogent connections between the antibiotics therapy and the improvement in the clinical picture, no well-founded conclusions as to etiology can be derived for the uveitis or necrotizing (chorio-)retinitis patients in question. The successful treatment of problematic cases identifies therapy with antibiotics as a therapeutic alternative.