Acquired Immunodeficiency Syndrome Presented as Atypical Ocu
The 38-year-old woman was referred with metamorphopsia and reduced vision in the right eye over the past 3 weeks. At the time of the presentation, she mentioned anorexia and losing 10kg in the past three months, and signs of anemia like paleness of face skin, bed nails, and bilateral angular cheilitis were observed. Uncorrected visual acuity in the right eye was counting fingers at two meters. Posterior synechia (PS) and pigment deposit over the anterior crystalline lens capsule precluded precise refraction in this eye. Slit-lamp examination revealed granulomatous keratic precipitates (KPs) distributed in Arlt's triangle, 2+ cells in the anterior chamber, and a relatively broad-based PS causing a keyhole appearance in the pupil. The crystalline lens was clear and 2+ cells were present in the anterior vitreous. Fundus examination was remarkable for a white patch surrounding a scar, inferonasal to the optic disc with three-disc diameter size. Some fibrous bands were emanating from the lesion, and the retina around this region was detached with considerable extension towards the superior, nasal, and inferior periphery, while no breaks could be appreciated. The vision in the left eye was 20/20, and ophthalmic examination was unremarkable in this eye.

Imaging studies including chest-X-ray, abdominal sonography, and age-related neoplastic workup including mammography, Pap smear, and colonoscopy were unremarkable except for nonspecific polyps in the patient's large intestine. Enzyme-linked immunosorbent assays (ELISA) for HIV antibodies came back positive which was later confirmed with the Western blot test. Once the diagnosis of toxoplasmic retinochoroiditis in an immunosuppressed patient was established, treatment with trimethoprim/sulfamethoxazole (TMP/SMX) 160/800 mg twice daily was commenced. Brain magnetic resonance imaging (MRI) showed multiple ring-enhancing lesions in both cerebral cortices. Meanwhile, three weeks after initial ophthalmic presentations, the patient developed a right hemiparesis. Due to the numerous lesions in the patient's motor cortex in the left and right lobes, the diagnosis of toxoplasmic encephalitis was made for the patient.

Highly active antiretroviral therapy (HAART) was added to her antitoxoplasmosis treatment four weeks after initial presentation and the dose of trimethoprim/sulfamethoxazole (TMP/SMX) increased to 160/800 mg/three times a day and azithromycin 250mg/daily was added to the antitoxoplasmic regimen. The systemic steroid was not added to the patient's treatment regimen due to concerns about the patient's immunosuppression. Two months after initial presentation, vitreous inflammation decreased substantially, subretinal fluid gradually resolved, and the uncorrected visual acuity improved to 20/100. Yellow subretinal hard exudates appeared in the perifoveal area with complete reattachment of the retina in three months. Two months after starting HAART, the patient's hemiparesis improved significantly during this time.