The presence of cells in the anterior chamber and vitreous cavity, large Kps, PS, and a patch of retinitis adjacent to a pigmented retinochoroidal scar are clinical clues to the diagnosis of toxoplasmic retinochoroiditis. Positive Toxoplasma IgG antibody along with negative IgM indicates infection with the organism at some time.[2, 9, 10] However, this case shows some ocular and systemic features that are not commonly expected in the typical case of toxoplasmic retinochoroiditis. In this case, pursuing these atypical features, led us to the diagnosis of AIDS. The first red flag was the presence of an extensive retinal detachment. Although tractional, exudative and rhegmatogenous retinal detachments can occur in ocular toxoplasmosis, such reports are limited; the reported prevalence of retinal detachment in acquired toxoplasmosis varies between 2.5 to 11 percent which is mostly of tractional or rhegmatogenous type.[10–13]
Angular cheilitis and significant weight loss, are not expected to occur in typical ocular toxoplasmosis. The presence of angular cheilitis calls for investigating the possibility of anemia and its underlying etiology. In our case, CBC revealed bicytopenia (anemia and leukopenia) which necessitates a thorough investigation for immunodeficiency.
Increased energy expenditure happens in the setting of opportunistic infections. Weight loss in patients with HIV is associated with poor prognosis, increased risk of disease progression and opportunistic pathology.[14]
In a study by Neves et al on 37 immunocompetent patients with acute acquired toxoplasmosis the frequency of systemic manifestations was inspected. Weight loss, anemia, and leukopenia were seen in 62.2%, 10.8% 16.2% of patients, respectively.[9]
The possibility of toxoplasmic encephalitis should be investigated in every patient with HIV and retinochoroidal toxoplasmosis. The study of choice for this purpose is brain MRI with contrast that can illustrate characteristic enhancing ring lesions. While not pathognomonic, the presence of several brain abscesses is the most characteristic feature of T. gondii infection in AIDS patients. Autopsy usually shows a global involvement of both hemispheres, though the basal ganglia and the corticomedullary junction are the most common sites of involvement.[6–8]
There are several reports on the management of retinal detachment in the setting of ocular toxoplasmosis. Among the 193 patients with ocular toxoplasmosis, Kianersi et al reported five patients with RD: three rhegmatogenous and two tractional. All five patients underwent vitrectomy or scleral buckling surgery. It is well known that severe intraocular inflammation can lead to tractional retinal detachment. With the progression of traction, a retinal hole and subsequent rhegmatogenous detachment may develop. Another possible mechanism of hole formation is the occurrence of full-thickness necrosis in the retinitis patch. [13]
In another study, Al-Zahrani et al reported a 24-year-old man with exudative RD secondary to reactivation of a toxoplasmosis lesion, which was successfully managed with anti-toxoplasmosis treatment.[11]
In a study by Faridi et al, on thirty-five eyes of 28 patients with ocular toxoplasmosis and sufficient follow-up, they identified 4 eyes (11 percent) with secondary RD, which was either rhegmatogenous, tractional, or a combination of the two. All eyes with retinal detachment underwent surgical repair of which 50% developed recurrent RDs (two of 4 patients). They concluded that handling ocular toxoplasmosis and related RDs may necessitate several measures, including surgical management, systemic therapy, and intravitreal injections. formation of new breaks or PVR-related complications may necessitate multiple surgeries in cases with recurrent RD.[12] Our case represents the exudative type of detachment with no distinct retinal break. Observation of a retinal fold may advocate the presence of a tractional component in this case. The resolution of RD following an anti-toxoplasmic regimen and HAART and without surgical intervention may suggest that decision upon surgery should not be rushed in such patients and a period close followup visits for ocular examination combined with appropriate systemic treatment may be warranted.
This report highlights the fact that sometimes the eyes are the site of the first presentation of a systemic life-threatening condition and emphasizes the role of ophthalmologists in such cases. Judicious ocular and systemic evaluation of patients with ocular toxoplasmosis are of utmost importance. In cases of atypical presentation, appropriate laboratory tests and CNS imaging should be requested. Systemic treatment with anti-toxoplasmosis regimens and HAART is mandatory in AIDs patients with ocular toxoplasmosis. Treatment options for retinal detachment in this setting should be meticulously approached.