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Frosted Branch Angiitis With Ocular Toxoplasmosis
Jason Edward Ysasaga, MD;
Janet Davis, MD
Arch Fam Med. 2000;9:962-963.
A HEALTHY, 17-year-old black female adolescent complained of sudden loss of vision in her right eye. There was a 3+ cellular reaction and abnormal results from fundus examination and angiography (Figure 1 and Figure 2). A chorioretinal infiltrate developed (Figure 3). Results of the blood toxoplasma IgG enzyme-linked immunosorbent assay were 2.06 (high positive). Antitoxoplasmosis medications were started, prednisone was tapered, and the fundus changes were resolved (Figure 4).
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Figure 1. Fundus photograph of the right eye shows diffuse sheathing of all retinal vessels, perivenular hemorrhages, serous macular detachment, and a pigmented chorioretinal scar. Visual acuity was counting fingers with a 3+ relative afferent pupillary defect. Visual acuity was 20/20 OS.
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Figure 2. Fluorescein angiography demonstrates prominent leakage of dye from the retinal vessels, but no vascular occlusions. The chorioretinal scar is hypofluorescent. Treatment with 1 mg/kg of oral prednisone daily and 1% topical prednisolone acetate was begun.
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Figure 3. Two days after starting treatment with oral corticosteroids, there is reduced vascular sheathing. A chorioretinal infiltrate is now visible inferior to the preexisting scar. Visual acuity was 3/200 OD. Treatment with a 6-week course of 50 mg of pyrimethamine daily and 1 g of sulfadiazine daily was begun. The dosage of oral prednisone was tapered over 3 weeks.
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Figure 4. Three months after initial evaluation, there is retinovascular narrowing, central macular pigment change, mild optic nerve pallor, and a new chorioretinal scar in the region of the retinal infiltrate seen in Figure 3. Visual acuity was 20/25 OD.
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COMMENT
Frosted branch angiitis was first described in Japan as a "bilateral acute uveitis with severe sheathing along all of the retinal vessels."1 Unilateral cases also occur.2 Although most cases are idiopathic, concomitant leukemia, lymphoma, autoimmune diseases, and elevated titers to streptolysin and Epstein-Barr virus have been reported.2-3 Eyes with active cytomegalovirus retinitis may also develop frosted branch angiitis.4 Whether frosted branch angiitis is a distinct clinical entity or a variety of disorders sharing the same fundus appearance is unclear.5 In idiopathic cases, treatment with oral corticosteroids has been recommended.2
To our knowledge, this is the first report of frosted branch angiitis secondary to toxoplasmic chorioretinitis. Although periarteritis related to toxoplasmosis is common, the diffuse sheathing of arteries and veins with submacular exudation is more typical of acute idiopathic frosted branch angiitis. Other than the infiltrate that became visible after 2 days and chorioretinal scar formation, this case behaved like acute idiopathic frosted branch angiitis with a rapid response to corticosteroids, good return of vision, and residual vascular narrowing.
Toxoplasmic chorioretinitis should be considered a cause of frosted branch angiitis in eyes with preexisting chorioretinal scars because the active chorioretinitis may initially be obscured by the exuberant inflammatory reaction. Specific antibiotic therapy in addition to corticosteroids is warranted when frosted branch angiitis is caused by an infectious agent.
AUTHOR INFORMATION
Selected from Arch Ophthalmol. 1999;117:1260-1261. Photo Essay.
From the Bascom Palmer Eye Institute, Miami, Fla.
REFERENCES
1. Watanabe Y, Takeda N, Adachi-Usami E. A case of frosted branch angitiis. Br J Ophthalmol. 1987;71:553.
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2. Sugin SL, Henderly DE, Friedman SM, Jampol LM, Doyle JW. Unilateral frosted branch angiitis. Am J Ophthalmol. 1991;111:682-685.
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3. Kleiner RC, Kaplan HJ, Shakin JL, Yanuzzi LA, Croswell HH Jr, McLean WC Jr. Acute frosted retinal periphlebitis. Am J Ophthalmol. 1988;106:27-34.
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4. Rabb MF, Jampol LM, Fish RH, Campo RV, Sobol WM, Becker NM. Retinal periphlebitis in patients with acquired immunodeficiency syndrome with cytomegalovirus retinitis mimics acute frosted retinal periphlebitis. Arch Ophthalmol. 1992;110:1257-1260.
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5. Kleiner RC. Frosted branch angiitis: clinical syndrome or clinical sign? Retina. 1997;1997:370-371.
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