Retinochoroidal toxoplasmosis in a patient with cerebral post-transplant lymphoproliferative disease of Hodgkin’s type: a diagnostic challenge
© Mittal et al. 2015
Received: 25 January 2015
Accepted: 29 July 2015
Published: 4 August 2015
Toxoplasmosis is a relatively rare complication in renal transplant patients and can pose diagnostic challenges, especially when it manifests as an ocular inflammation. Authors hereby report an unusual case of a 57-year-old male who developed retinochoroidal toxoplasmosis after 15 years of renal transplant, the diagnoses of which were challenging as the patient was also a known case of cerebral post-transplant lymphoproliferative disease (PTLD) of Hodgkin’s type, which misled the ophthalmologists towards a clinical diagnosis of ocular PTLD. Histopathology examination of the enucleated eye revealed numerous toxoplasmosis cysts within the retina and choroid. No ocular PTLD was observed.
KeywordsRetinochoroidal toxoplasmosis Renal transplant Post-transplant lymphoproliferative disease Retinal necrosis Toxoplasmosis infection Hodgkin’s disease Uveitis Oculocerebral Inflammation Histology
Although reported previously, retinochoroiditis due to toxoplasmosis is relatively rare in renal transplant patients . A definitive timely diagnosis in such cases can be challenging, particularly in atypical clinical presentations, as in our patient, who was also diagnosed with cerebral post-transplant lymphoproliferative disease (PTLD) of Hodgkin’s type [2, 3]. The presentation of bilateral extensive uveitis due to retinochoroidal toxoplasmosis 15 years after renal transplantation, but clinically suspected to be an oculocerebral PTLD, has not been reported previously to our knowledge.
Histological sections demonstrated an enlarged globe with focal scleral thinning. Moderately dense chronic inflammatory infiltrates were seen in the anterior chamber, iris stroma, ciliary muscles, anterior vitreous and entire choroid, with focal vasculitis (Fig. 3b). The retina was near-to-completely necrotic (Fig. 3c, asterisk marked) with the remaining viable areas being detached. Focal areas of retinal scarring, with RPE proliferation at the scar edges, were seen (Fig. 3d). Within the necrotic retina, numerous toxoplasmosis cysts were observed (Fig. 3e, arrows); these were confirmed on immunohistochemistry (Fig. 3f). There was no evidence of any Hodgkin-like CD30+/EBV+ cells despite numerous levels being performed. A diagnosis of extensive chronic uveitis with necrotic retinochoroiditis caused by Toxoplasma gondii was made. Subsequent cerebrospinal fluid and serum examinations were positive for T. gondii by PCR and enzyme-linked immunosorbent assay. This contrasted subsequent cerebral biopsies, which showed neither toxoplasmosis cysts nor residual PTLD cells. Furthermore, the blood toxoplasma IgG levels were only slightly elevated, and IgM was negative. The patient received treatment with combination of pyrimethamine, sulfadiazine and clindamycin; however, he unfortunately succumbed to the combined disease processes shortly thereafter.
This case illustrates a number of unusual pathologies and clinical challenges. Firstly, it describes a case of cerebral PTLD of Hodgkin-type, which has been never reported in the literature. Secondly, it exemplifies the fact that an open mind must be kept in the differential diagnosis of immunosuppressed patients with a “masquerade syndrome”-like presentation. Although the main clinical suspicion in the present case was intraocular involvement of the cerebral PTLD, the differential diagnosis of intraocular toxoplasmosis was equally highly ranked, considering the medical history of the patient. Fulminant toxoplasmosis in post-transplant patients may occur as a primary infection shortly after transplantation or as reactivation of latent infection, even up to 7 years after transplantation . It may have variable uveal involvement and can progress rapidly to panophthalmitis and even orbital cellulitis . Hence, dual pathologies coexisting in a single patient, possibly at the same  or different sites, must always be considered, and early diagnosis of these entities, although challenging, is essential.
Epstein Barr virus
post-transplant lymphoproliferative disease
The authors would like to thank Mr Simon Biddolph, Biomedical Scientist and Advanced Practitioner in Ophthalmic Pathology at the Royal Liverpool University Hospital, for the excellent histological sections provided of the case presented.
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