A 19-year-old immunocompetent female presented with painful diminution of vision in the left eye since 10 days. It had a sudden onset with rapid progression. It was not associated with floaters or visual phenomena during the initiation or course of the symptoms. She denies any history of trauma, allergy, or systemic associations except for the history of jaundice 1 month back from which she has now made a total recovery. She is a waitress by profession, non-vegetarian, and gives the history of frequent consumption of undercooked meat of goat, pork, and buffalo.On examination, vision in the right eye (RE) was 6/6 and in the left eye (LE) was perception of light (PL) with accurate projections. The right eye had grossly normal anterior and posterior segment findings. On the examination of the left eye, there was the presence of circumcorneal congestion; mutton-fat keratic precipitates over the endothelium and Koeppe’s nodules at the pupillary margin of the iris. The reaction in the anterior chamber was intense with cells 4+ and flare 4+.
On the examination of the posterior segment, the eye had 4+ vitreous haze and poor red reflex. Further details of the fundus could not be appreciated
Intraocular pressure was 15 mmHg in the RE and 13 mmHg in the LE. The ultrasonography of the left eye was mandated immediately. It revealed a band-like hyperechogenic structure extending from the vitreous base towards the posterior hyaloid surface converging around optic nerve head. This radiological finding was persisting in low gain which suggested of vitritis along with wide anterior and narrow posterior retinal detachment of funnel shape.
A provisional diagnosis of acute granulomatous panuveitis with a retinal detachment of the left eye was made with acute retinal necrosis (ARN) as a probable cause. Tailored laboratory investigations were sent, and treatment with oral acyclovir and oral corticosteroid was started immediately. The laboratory reports for IgM and IgG for TORCH infection were negative. Serological tests for HIV, HCV, and HBsAg were also negative. PCR for herpes virus family could not be performed due to unavailability. The patient then underwent diagnostic and therapeutic vitrectomy using 23G (25 mm) (0.6 mm bore) cutter via the pars plana route. There was the presence of dense vitreous exudate with multiple atrophic holes near the ora with near total retinal detachment. The optic nerve was found to be slightly pale. The vitreous sample (0.5 ml) was retrieved and sent for cytology and toxoplasma IgG titer.Toxoplasma IgG vitreous titer was raised significantly to 1:16. To everyone’s surprise, the microbiological examination of the vitreous yielded bradyzoites of Toxoplasma in H&E staining and tachyzoites in Giemsa staining. This confirmed the diagnosis of atypical ocular toxoplasmosis.