PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of pamjEditorial  boardAbout the Pan African Medical JournalInstructions for authorsPAMJ
 
Pan Afr Med J. 2015; 20: 233.
Published online 2015 March 12. doi:  10.11604/pamj.2015.20.233.5097
PMCID: PMC4919701

Severe ocular sequelae of congenital toxoplasmosis: huge macular scar

Abstract

Retinochoroiditis is the most common ocular manifestation of congenital toxoplasmosis, but other associated ophthalmological pathologies can also occur. Ophthalmologists are rarely able to distinguish between toxoplasmic retinochoroiditis due to infection acquired before or after birth, unless other clinical or serological indications are present. This article reports a case of a 3-year-old boy with abnormalities suggestive of congenital toxoplasmosis. The clinical and complementary examinations are discussed. The education of pregnant women is crucial for the prevention of congenital toxoplasmosis. Awareness of antenatal and postnatal presenting signs and symptoms is important for clinicians, because early diagnosis and treatment may minimize sequelae. Untreated, the majority of affected infants will develop chorioretinitis, deafness and/or neurological symptoms.

Keywords: Congenital toxoplasmosis, retinochoroiditis, sequelae

Introduction

Retinochoroiditis is the most common ocular manifestation of congenital toxoplasmosis, but other associated ophthalmological pathologies can also occur [1]. Ophthalmologists are rarely able to distinguish between toxoplasmic retinochoroiditis due to infection acquired before or after birth, unless other clinical or serological indications are present [2]. Awareness of antenatal and postnatal presenting signs and symptoms is important for clinicians, because early diagnosis and treatment may minimize sequelae [3].

Patient and observation

A 3 year-old boy of a not followed pregnancy presented with an 8 months history of exotropia of the left eye (Figure 1). Cycloplegic refraction was -0.25 and 0.00 in the right and left eyes respectively.

Figure 1
Exotropia for the left eye

An initial objective assessment of the visual function showed a best corrected visual acuity of 12/10 in the right eye and Counting fingers at 1m in the left eye. Examination of the anterior segment was unremarkable in both eyes. Fundoscopy revealed macular scar of about 3 papillary diameters (Figure 2).

Figure 2
Macular scar of about 3 papillary diameters

The optical coherence tomography (OCT) of the macula reveals a disorganization of retinal architecture related to a sequelae of Retinochoroiditis at the left eye (Figure 3). General examination was unremarkable including the neurological examination. Although we have no serological evidence of congenital infection, we conclude to the diagnosis of macular sequelae secondary to congenital toxoplasmosis based on the following arguments: the presence of a toxoplasmic retinochoroiditis, no acute ocular symptoms, a history of squint in affected eye and a notion of untreated febrile episode during the pregnancy.

Figure 3
Optical coherence tomography (OCT) of the macula reveals a disorganization of retinal architecture related to a sequelae of retinochoroiditis

Discussion

Retinochoroiditis is the most common ocular manifestation of congenital toxoplasmosis [1]. The other clinical manifestations of congenital ocular toxoplasmosis were choroidal coloboma, strabismus, nystagmus, ptosis, microphthalmia, cataract and enophthalmia [4]. Epidemiological evidence suggests that most adult disease arises from infection acquired after birth [5]. Much less is known about the prevalence of infection before and after birth in children with toxoplasmic retinochoroiditis. Ophthalmologists are rarely able to distinguish between toxoplasmic retinochoroiditis due to infection acquired before or after birth, unless other clinical or serological indications are present [2].

Knowledge of the relative contribution and severity of infection acquired before and after birth to symptomatic ocular toxoplasmosis in children would inform counselling and the public debate on the relevance of screening programmes for children [6].

Retinochoroidal lesions due to infection before and after birth were indistinguishable. The presence of bilateral, multiple or posterior pole lesions did not distinguish between the two groups, but most children (84%) presenting with acute ocular symptoms had postnatally acquired infection. Children infected before birth were most likely to be detected through abnormal vision screening or ocular appearance. Children infected after birth all presented with acute ocular symptoms. The site of lesion was similar, regardless of when infection occurred [2].

Conclusion

Retinochoroiditis is the most common ocular manifestation of congenital toxoplasmosis [1]. The education of pregnant women is crucial for the prevention of congenital toxoplasmosis. Untreated, the majority of affected infants will develop chorioretinitis, deafness and/or neurological symptoms [3].

Competing interests

The authors declare no competing interest.

Authors’ contributions

All authors contributed to the work and write-up of the manuscript. All authors read and agreed to the final version of this manuscript and equally contributed to its content and to the management of the case.

References

1. Suhardjo Utomo PT. Clinical manifestations of ocular toxoplasmosis in Yogyakarta, Indonesia: a clinical review of 173 cases. Southeast Asian J Top Med Public Health. 2003;34(2):291–7. [PubMed]
2. Stanford MR, Tan HK. Toxoplasmic retinochoroiditis presenting in childhood: clinical findings in a UK survey. Br J Ophthalmol. 2006 Dec;90(12):1464–1467. [PMC free article] [PubMed]
3. Hoekstra F, Buzing C. Congenital toxoplasmosis: severe ocular and neurological complications. Ned Tijdscr Geneeskd. 2011;155(18):A2853. [PubMed]
4. Kodjikian L, Wallon M. Ocular manifestations in congenital toxoplasmosis. Graefes Arch Clin Exp Ophthalmol. 2006 Jan;244(1):14–21. [PubMed]
5. Gilbert RE, Stanford MR. Is ocular toxoplasmosis due to prenatal or postnatal infection. Br J Ophthalmol. 2000;84(2):224–226. [PMC free article] [PubMed]
6. OConnor GR. Manifestations and management of ocular toxoplasmosis. Bull N Y Acad Med. 1974 Feb;50(2):192–210. [PubMed]

Articles from The Pan African Medical Journal are provided here courtesy of African Field Epidemiology Network