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7/28/2019 Toxoplasmosis (Dr. Michael)
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Dr. Michael Indra Lesmana, Sp.M
PID-FK.UKRIDA
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Manifestation of TB-Eye
unilateral - typically affects
children photophobia, lacrimation
blepharospasm delayed hypersensitivity
to tuberculin protein topical steroids /steroid-
ab
Phlyctenulosis
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Intraocular Tuberculosis
Intraocular tuberculosis represents an extrapulmonaryform of the disease and they are seen in more than50% of the patients who have both AIDS andtuberculosis
Jones et al: showed that the risk of extrapulmonary TB
was higher in patients with low CD4 +counts
great mimicker of various uveitis entities
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n ca resen a on n n raocu ar
Tuberculous1.Anterior uveitis:
Granulomatous,nongranulomatous, iris nodules and ciliary bodytuberculoma
2. Intermediate uveitis :
Granulomatous
pars planitis/peripheral uvea
3. Posterior and panuveitis
Choroidal tubercleChoroidal tuberculoma
Subretinal abscess
Serpiginous-like choroiditis
4. Retinitis and retinal
vasculitis
5. Neuroretinitis and opticneuropathy
6. Endophthalmitis andpanophthalmitis
Eales disease
is considered by some to reflecttuberculous infection orhypersensitivity
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Case of patient with Anterior
Uveitis (A) Anterior segmentphotograph showingfibrinous inflammation ina 42-year-old man.His visual acutity was
reduced to counting fingers
(B)Ultrasoundbiomicroscopy showsexudates in pars plana
(C ) MRI shows cavitarylesion
(D) Sputum positive foracid-fast-bacilli.
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Posterior and Panuveitis In tuberculous posterior uveitis, the ocular changes
can be divided into four groups:
1.Choroidal tubercles2.Choroidal tuberculoma
3.Subretinal abscess
4.Serpiginous-like choroiditis
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Choroidal Tubercles
The most common intraocular manifestation
of tubercular posterior uveitis
Right eye of a 24-year-old woman withtubercular meningitisshowing optic diskedema, multiple smallchoroidal tubercles,and a healed choroidaltuberculoma temporalto the fovea with retino-
choroidal anastamosis.
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Choroidal Tuberculoma
(A) There are twogranulomas in the uppertemporal and lower nasal
quadrant in the right eye
In view of a stronglypositive Mantoux test ( >20mm induration) andpositive
chest x-ray, patient wasgiven ATT withconcomitant oralcorticosteoids.
Fundus photofraph RE ofa 45-year old man
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Tubercular Retinal Vasculitis
Patient with systemictuberculosis showing
vasculitis
Polymerase chainreaction from the
vitreous humor was
positive for M.tuberculosis.
Right eye of a 43-year-old man
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Endophthalmitis - Panophthalmitis
Acute onset and shows rapid progression withdestruction of the intraocular tissues
The inflammation may be intense enough to producehypopyon, filling the anterior chamber with purulentmaterial and involving the cornea
In panophthalmitis, the sclera is also involved, whichmay result in globe perforation.
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A case 22 yo,F, Protursion OD
Panophthalmitis ec TB .OD
UTZ
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Post TB drugs treatment
Advised forevisceration
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Diagnosis Clinical indicators
Corroborative evidence
(Purified Protein Derivative, Chest Radiography andComputerized Tomography, Serodiagnosis or ELISA)
Direct evidence
(Acid-Fast, Culture of Intraocular Fluid/Tissue,
Polymerase Chain Reaction)
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Diagnosis QuantiFERON is an approved, antigen specific test
that utilizes synthetic peptides representingMycobacterium tuberculosis proteins
Including latent tuberculosis infection (LTBI) andtuberculosis (TB) disease
This test was approved by the U.S. Food and
Drug Administration (FDA) in 2005.
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QuantiFERON Blood samples are mixed with antigens
The advantages:
> Is not subject to reader bias that can occur withMantoux test
> Is not affected by prior BCG (bacille Calmette-Gurin) vaccination
A positive result suggests thatM. tuberculosis infectionis likely; a negative result suggests that infection isunlikely
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Diagnosis
Level
evidencefor
diagnosisocular TB
Level I
Identification M.Tbin Ocular
fluid/tissueLevel II
Identification M.Tbin Other
fluid/tissue(eg.Lung)
Level III
Suggestive pattern of
intraocularinflammation
+
Suggestive clinical onsystemic exam &
Radiological
Staining,culture, PCR,
histopath
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Treatment
MEDICAL MANAGEMENT
1. Drug Regimens for Treating Intraocular
Tuberculosissimilar to those for pulmonary orextrapulmonary tuberculosis
Comanagement with pulmonologist/internist
2. Duration of Treatment
The initial regimen: RHZE. Pyrazinamide and ethambutolwere stopped after 2 to 3 months and treatment withisoniazid and rifampin was
continued for 9 to 12 months
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3. Concomitant Use of Corticosteroids/Immunosuppressive Agents
Low-dose systemic corticosteroids used for 4 to 6wks,along with multidrug ATT, may limit damage to oculartissues caused from delayed type hypersensitivity
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5. Ocular Side Effects of Anti-Tubercular Drugs
The ethambutol toxicity is rare if the daily dose doesnot exceed
15mg/kg.
Of the patients receiving daily dose of 25 mg/kg ormore, 1--2% experience ocular toxicity
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HIV-AIDS Selected Anterior segment manifestation:
Molloscum contagiosum, HZO, Herpes simplex ,Kaposi sarcoma
Most Common Posterior segment manifestation: HIVRetinopathy, CMV retinitis
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Molluscum contagiosum HZO
Molluscum contagiosum, characterized bycutaneous nodules
Painful, dermatoform, clustervesicobullous
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Herpes simplex Kaposi Sarcoma (KS)
Painless, dendritic, decreased of cornealsensibility, recurrent
Nodul, reddish, painless, vascular,eyelid, conj- orbit
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HIV Retinopathy Ocular micro-angiopathic syndrome
Non-infectious microvascular disorder characterisedby cotton wool spots, microaneurysms, retinalhaemorrhages, Roth spots, telangiectatic vascularchanges and areas of capillary non-perfusion
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HIV Retinopathy
Cotton-wool spots (CWS) are the most commonocular micro-angiopathic manifestations of
HIV/AIDS
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CMV-Retinitis
CMV retinitis was afrequentopportunisticinfection amongpatients with AIDStypically occurred in
patients with CD4 Tcells (helper T cells)50 cells/L
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CMV-Retinitis Cytomegalovirus retinitis has been reported to
affect up to 25% to 40% of HIV patients and is themost common cause of visual loss
Highly active antiretroviral therapy (HAART)effectively suppresses HIV replication, resulting in
immune recovery, which, if sufficient, controlsretinitis without anti-CMV therapy.
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CMV-Retinitis Treatment The induction regimen consisted of injection of 2
mg/0.04 ml ofganciclovir twice weekly for 4 weeks
followed by a similar dose weekly for 4 weeks and thena weekly maintenance regimen of 1.0 mg/0.02 mlganciclovir
anti-CMV drugs are virostatic, and treatment has to be
given in a continuous to prevent recurrence of thedisease.
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TOXOPLASMOSIS This is a case of a 20 y.o F with blurring of vision 1 week
ptc.
Associated with eye soreness, mild eye redness, seeingfloaters and half of visual defect.
Pt likes to consume street food satae
No fever nor cough. (-) history of allergic
Had prior consult but gain no relief
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Ophthalmological StatusOD OS
VA : 2/60 (inferior side)
Mild ciliary injection
Clear cornea
-f/-c
+2 vitreous cell
IOP 59 mmHg
Full EOM
+/+RC(-)RAPD
VA : 1.0
No injection
Clear cornea
-f/-c
- vitreous cell
IOP 12 mmHg
Full EOM
+/+RC (-)RAPD
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Fundus Photo pre-treatment
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Ancillary Test
Ro Thorax PA :Mild Infiltrate on left
parahilerAorta Calsification
Ass:BronchopneumoniaDD/ Pulmonary TB
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Hematologi Immunologi
Hb 13.9 g/dl
L 9.2
0/1/2/76/21/0
Ht 43
Tromb 285.000
Blood sugar 126mg/dl
Ig G Toxoplasma
(+) 100 IU/ml
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Diagnosis and Treatment Posterior Uveitis (Retinochoroiditis) ec Toxoplasmosis
OD with secondary glaucoma
Meds: Ab-steroid topical 6x OD
Timolol 0.5% 2x OD
Cotrimoksazol forte 2x 1 tab
Acetazolamide 250mg 3x 1 tab
Methylprednisolone 1 x 48mg pcKalium oral 2x1 tab
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1 week post treatment OD : VAD sc 0.5 ()
BCVA S-1.00 c -0.50 x 160 --- 0.8
(-) ciliary injection(-) vit cell
IOP 10 mmHg ()
OS : VAD sc 1.0
IOP 12 mmHg
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Fundus Photo 2nd wk post tx
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Fundus Photo pre & 3rd wk post tx
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THANK YOU