J Daniel Diaz1,3*, Jorge L Bustillo2, Idarmes C Pacheco2 and David C Gritz3,4
1Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
2Instituto Superior de Ciencias Medicas de Sancti Spiritus, Cuba
3Albert Einstein College of Medicine, Department of Ophthalmology, Montefiore Medical Center, Bronx, New York, USA
4King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
Received: 13 Oct, 2016; Accepted: Oct, 2016; Published: 25 Oct, 2016
Jose Daniel Diaz, MD, 221 Newbury St, STE 3F, Boston, MA, 02116, USA, Tel: 305-794-6117; E-mail:
Diaz JD, Bustillo JL, Pacheco IC, Gritz DC (2016) Cuban Ocular Toxoplasmosis Epidemiology Study (COTES): Clinical Features in 279 Patients from Central Cuba. J Clin Res Ophthalmol 3(1): 027-033. 10.17352/2455-1414.000032
© 2016 Diaz JD, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Epidemiology; International ophthalmology; Ocular toxoplasmosis; Posterior uveitis
Purpose: To characterize the clinical features of ocular toxoplasmosis (OT) in Central Cuba.
Methods: A database at a large regional referral center was searched for patients who, from April 1, 2011 to May 31, 2013, had the potential diagnosis of OT. Inclusion criteria were the clinical diagnosis of OT, characterized by focal retinochoroidal inflammation. Medical records were reviewed to confirm inclusion criteria (visual acuity recorded in decimal form).
Results: 279 patients (329 total eyes) were affected with OT. Overall, 66.7% were diagnosed with acquired OT with a mean age of 35.4 years and 1.8% with congenital OT with a mean age of 3.4 years. The time of onset of OT could not be determined in 28.3% (n=79) of patients. Patient clinical presentations were posterior uveitis (72.8 %), quiescent retinochoroiditis (16.1 %), and panuveitis (11.1%). Fourteen percent of patients had a slight decrease (0.9-0.6) in visual acuity, 44.4% a moderate decrease (0.5-0.2), and 41.6% a marked decrease (< 0.1).
Conclusion: There exist large numbers of patients with active toxoplasmic uveitis in the Central Cuban region. To our knowledge, this is the first report in the English medical literature describing OT in the Cuban population.
Toxoplasma gondii, an obligate intracellular protozoan with a broad range of hosts, continues to be the most common cause of infectious posterior uveitis in humans . Cats are the definitive hosts for T. gondii, and humans and other mammals continue to act as intermediate hosts. The transmission occurs by many routes, including ingestion of raw or undercooked meat infected with tissue cysts, ingestion of food and water contaminated with oocysts, ingestion of eggs and milk contaminated with tachyzoites, blood transfusion, organ transplantation, and even transplacental transmission [1,2]. Interestingly, visual symptoms during acute toxoplasma retinochoroiditis are typically secondary to vitritis. Vision loss may become permanent due to formation of a macular scar or the presence of optic atrophy. Although the classic triple-drug therapy of pyrimethamine, sulfadiazine, and corticosteroid is an effective choice, alternative treatment regimens including single agent treatment with trimethoprim-sulfamethoxazole, intravitreal injection of clindamycin with dexamethasone, or combination of azithromycin with pyrimethamine have been shown to be effective against ocular toxoplasmosis [1-3].
Despite its worldwide prevalence, worldwide rates of ocular toxoplasmosis (OT) infection differ, with under-developed countries having higher rates of infection. The prevalence of OT has been reported to be higher in tropical regions, with seroepidemiological research examining OT in Brazil and Colombia showing that there is an increased prevalence in South America, Central America, and the Caribbean compared to North America and Europe [1-3].
Although demographics and clinical manifestations of OT have been extensively described in large parts of the world, there continues to be a lack of characterization of OT in the Caribbean. The aim of this non-comparative case series is to describe the clinical features and demographics of OT in patients evaluated at a large tertiary referral center in previously unassessed Central Cuba.
Materials and Methods
A retrospective study of the medical records of patients seen and evaluated at the Centro Oftalmológico Provincial hospital in Sancti Spiritus, Central Cuba was performed. The Centro Oftalmológico Provincial hospital, opened in 2007, is a large tertiary referral center that serves patients in a catchment area spanning over 20 municipalities (in 5 provinces) in Central Cuba. The majority of patients are seen from within the Sancti Spiritus province, which is made up of eight municipalities (Figure 1). A prospective database kept by physicians at the center was used to identify all patients coded with the diagnosis of OT during a consecutive 24-month period from April 1, 2011, through March 31, 2013. Medical records were reviewed to confirm inclusion criteria and gather demographic and clinical data.
- de-la-Torre A, Lopez-Castillo CA, Gomez-Marin JE (2009) Incidence and clinical characteristics in a Colombian cohort of ocular toxoplasmosis. Eye (Lond) 23: 1090-1093 .
- Glasner PD, Silveira C, Kruszon-Moran D, Martins MC, Burnier Júnior M, et al. (1992) An unusually high prevalence of ocular toxoplasmosis in southern Brazil. Am J Ophthalmol 114: 136-144 .
- Khan A, Jordan C, Muccioli C, Vallochi AL, Rizzo LV, et al. (2006) Genetic divergence of Toxoplasma gondii strains associated with ocular toxoplasmosis, Brazil. Emerg Infect Dis 12: 942-949 .
- Holland GN, Buhles WC, Jr., Mastre B, Kaplan HJ (1989) A controlled retrospective study of ganciclovir treatment for cytomegalovirus retinopathy. Use of a standardized system for the assessment of disease outcome. UCLA CMV Retinopathy. Study Group. Arch Ophthalmol 107: 1759-1766 .
- Bosch-Driessen LE, Berendschot TT, Ongkosuwito JV, Rothova A (2002) Ocular toxoplasmosis: clinical features and prognosis of 154 patients. Ophthalmology 109: 869-878 .
- Friedmann CT, Knox DL (1969) Variations in recurrent active toxoplasmic retinochoroiditis. Arch Ophthalmol 81: 481-493 .
- Holland GN, Crespi CM, ten Dam-van Loon N, Charonis AC, Yu F, et al. (2008) Analysis of recurrence patterns associated with toxoplasmic retinochoroiditis. Am J Ophthalmol 145: 1007-1013 .
- Atmaca LS, Simsek T, Batioglu F (2004) Clinical features and prognosis in ocular toxoplasmosis. Jpn J Ophthalmol 48: 386-391 .
- Holland GN (2003) Ocular toxoplasmosis: a global reassessment. Part I: epidemiology and course of disease. Am J Ophthalmol 136: 973-988 .
- Garweg JG, Scherrer JN, Halberstadt M (2008) Recurrence characteristics in European patients with ocular toxoplasmosis. Br J Ophthalmol 92: 1253-1256 .
- Gilbert RE, Dunn DT, Lightman S, et al. (1999) Incidence of symptomatic toxoplasma eye disease: aetiology and public health implications. Epidemiol Infect 123: 283-289 .
- Bonfioli AA, Orefice F (2005) Toxoplasmosis. Semin Ophthalmol 20: 129-141 .
- Burnett AJ, Shortt SG, Isaac-Renton J, King A, Werker D, et al (1998) Multiple cases of acquired toxoplasmosis retinitis presenting in an outbreak. Ophthalmology 105: 1032-1037 .
- Couvreur J, Thulliez P (1996) [Acquired toxoplasmosis of ocular or neurologic site: 49 cases]. Presse Med 25: 438-442 .
- Gilbert RE, Stanford MR (2000) Is ocular toxoplasmosis caused by prenatal or postnatal infection? Br J Ophthalmol 84: 224-226 .
- Holland GN (1999) Reconsidering the pathogenesis of ocular toxoplasmosis. Am J Ophthalmol 128: 502-505 .
- Tan HK, Schmidt D, Stanford M, Teär-Fahnehjelm K, Ferret N, et al. (2007) Risk of visual impairment in children with congenital toxoplasmic retinochoroiditis. Am J Ophthalmol 144: 648-653 .
- Meenken C, Assies J, van Nieuwenhuizen O, Holwerda-van der Maat WG, van Schooneveld MJ, et al. (1995) Long term ocular and neurological involvement in severe congenital toxoplasmosis. Br J Ophthalmol 79: 581-584 .
- Kodjikian L, Wallon M, Fleury J, Denis P, Binquet C, et al. (2006) Ocular manifestations in congenital toxoplasmosis. Graefes Arch Clin Exp Ophthalmol 244: 14-21 .
- Garza-Leon M, Garcia LA (2012) Ocular toxoplasmosis: clinical characteristics in pediatric patients. Ocul Immunol Inflamm 20: 130-138 .
- Soares JA, Nasser LS, Carvalho SF, Caldeira AP (2011) [Ocular findings in children with congenital toxoplasmosis]. Arq Bras Oftalmol 74: 255-257 .
- Cochereau-Massin I, LeHoang P, Lautier-Frau M, Zerdoun E, Zazoun L, et al. (1992) Ocular toxoplasmosis in human immunodeficiency virus-infected patients. Am J Ophthalmol 114: 130-135 .
- Holland GN (1989) Ocular toxoplasmosis in the immunocompromised host. Int Ophthalmol 13: 399-402 .
- Moorthy RS, Smith RE, Rao NA (1993) Progressive ocular toxoplasmosis in patients with acquired immunodeficiency syndrome. Am J Ophthalmol 115: 742-747 .
- Gagliuso DJ, Teich SA, Friedman AH, Orellana J (1990) Ocular toxoplasmosis in AIDS patients. Trans Am Ophthalmol Soc 88: 63-86 .
- Holland GN, Engstrom RE Jr, Glasgow BJ, Berger BB, Daniels SA, et al. (1988) Ocular toxoplasmosis in patients with the acquired immunodeficiency syndrome. Am J Ophthalmol 106: 653-667 .
- Biancardi AL, Curi AL (2013) Cat-Scratch Disease. Ocul Immunol Inflamm.
- Ray S, Gragoudas E (2001) Neuroretinitis. Int Ophthalmol Clin 41: 83-102 .
- Fish RH, Hoskins JC, Kline LB (1993) Toxoplasmosis neuroretinitis. Ophthalmology 100: 1177-1182 .
- Smith JR, Cunningham ET, Jr (2002) Atypical presentations of ocular toxoplasmosis. Curr Opin Ophthalmol 13: 387-392 .
- Eckert GU, Melamed J, Menegaz B (2007) Optic nerve changes in ocular toxoplasmosis. Eye (Lond) 21: 746-751 .
- Grossniklaus HE, Specht CS, Allaire G, Leavitt JA (1990) Toxoplasma gondii retinochoroiditis and optic neuritis in acquired immune deficiency syndrome. Report of a case. Ophthalmology 97: 1342-1346 .
- Holland GN, Lewis KG (2002) An update on current practices in the management of ocular toxoplasmosis. Am J Ophthalmol 134: 102-114 .
- Stanford MR, See SE, Jones LV, Gilbert RE (2003) Antibiotics for toxoplasmic retinochoroiditis: an evidence-based systematic review. Ophthalmology 110: 926-931 .
- Rothova A, Meenken C, Buitenhuis HJ, Brinkman CJ, BaarsmaGS et al. (1993) Therapy for ocular toxoplasmosis. Am J Ophthalmol 115: 517-523 .
- Bosch-Driessen LH, Verbraak FD, Suttorp-Schulten MS, et al. (2002) A prospective, randomized trial of pyrimethamine and azithromycin vs pyrimethamine and sulfadiazine for the treatment of ocular toxoplasmosis. Am J Ophthalmol 134: 34-40 .
- Yazici A, Ozdal PC, Taskintuna I, Kavuncu S, Koklu G (2009) Trimethoprim/Sulfamethoxazole and azithromycin combination therapy for ocular toxoplasmosis. Ocul Immunol Inflamm 17: 289-291 .
Follow us on Academia.edu
Access denied for user 'root'@'localhost' (using password: YES)