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HistoryA 26-year-old white man presented with a 4-day history of a scotoma in the left eye only.
Ancillary TestingOptical coherence tomography (OCT) of the left eye showed peripapillary nerve fiber layer edema (Figure 2) and a small, shallow, serous retinal detachment nasal to the nerve (Figure 3).
The workup of this patient included complete blood count, basic metabolic panel, B12, folate, angiotensin converting enzyme (ACE), antinuclear antibody (ANA), Bartonella and toxoplasma serologies, and fluorescent treponemal antibody (FTA-Abs). Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of the brain and orbits was performed with and without contrast, demonstrating normal signal of the optic nerves. All of the test results were negative, except for Toxoplasma serologies, which were equivocal for Immunoglobulin M (IgM). Macular optical coherence tomography (OCT) of the left eye showing peripapillary nerve fiber layer edema. Most cases of ocular toxoplasmosis are acquired instead of congenital.(7) The classic lesion in ocular toxoplasmosis is a focus of active retinochoroiditis adjacent to an old scar. Ultimately, our patient exhibited a toxoplasmic neuroretinitis, making this an atypical presentation of ocular toxoplasmosis. The most serious potential complication of ocular toxoplasmosis is Toxoplasma encephalitis. Ocular toxoplasmosis remains a clinical diagnosis, typified by a focus of retinochoroiditis with vitreous inflammation and an adjacent chorioretinal scar. Triple therapy for ocular toxoplasmosis is classically a combination of pyrimethamine, sulfadiazine, and prednisone. He characterized the visual field defect as greenish and fixed in a superotemporal, paracentral location. Examination of the left eye was pertinent for grade 1 vitreous haze (Figure 1) in the photographic scale described by Davis.(1) There was moderate optic nerve edema with adjacent flame hemorrhages (Figure 1). There is optic nerve edema and flame hemorrhage; vitreous haze, grade 1, was also appreciated. Late phase fluorescein angiography demonstrated staining of the left optic nerve (Figure 4). Capillaries supplying the optic nerve head demonstrate leakage that usually persists after resolution of the edema.

Other atypical forms include occlusive retinal vasculitis, retinal detachment, pigmentary retinopathies, panuveitis, optic neuropathy, and scleritis.(9) The presentations of toxoplasmosis are numerous and diverse.
Serology, while useful in identifying primary infection, is limited in differentiating between recurrent acquired and recurrent congenital infection. The visual change was sudden in onset and was not associated with other ocular complaints or headache.
After 2 months of follow-up, he showed resolution of disc edema, macular edema, and extramacular serous retinal detachment but only mild improvement of the original scotoma. Despite the absence of large studies on the incidence of encephalitis in patients with Toxoplasma neuroretinitis, likely due to its rarity, one should have a high index of suspicion and rule-out brain involvement in all patients with neurologic findings.
Past ocular history was remarkable only for a diagnosis of herpes simplex keratitis in the involved eye.
Cerebrospinal fluid was analyzed for cryptococcal antigen, oligoclonal bands, Herpes simplex virus (HSV) 1 and 2 polymerase chain reaction (PCR), cytomegalovirus (CMV) PCR, and India ink. In fact, it may be prudent to obtain baseline neuroimaging in all patients with suspected Toxoplasma neuroretinitis.
Infectious sources that can present similarly include syphilis, Bartonella, Toxoplasma gondii, Toxocara, HIV, HSV, CMV, tuberculosis, Borreila burgdorferi, Leptospira interrogans, Rickettsia typhi, cysticercosis, and Aspergillus.(3,4) Inflammatory conditions, such as multiple sclerosis, sarcoidosis, and systemic lupus erythematosus, also have similar presentations. Neoplastic diseases, such as meningioma, glioma, central nervous system lymphoma, and infiltrative metastatic disease with leptomeningeal involvement should also be included in the differential diagnosis. Conditions such as myelinated nerve fiber layer, and optic disc drusen can be mistaken for neuroretinitis. Social history was negative for antecedent travel, illicit drugs, or trauma, but was positive for cat exposure. Vascular diseases, including non-arteritic and arteritic anterior ischemic optic neuropathy, diabetic retinopathy, radiation retinopathy, and central retinal vein occlusion, also bear a resemblance when papillitis is present.
Stellate maculopathy and disc edema are the hallmark findings and may coincide with an adjacent serous retinal detachment.(2) Disc edema is often the initial sign followed by macular star formation approximately 1 week later with resolution of the peripapillary exudate.

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