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Posterior Seg.: Infectious Disease II (Chorioretinal Infection)

Terms in this set (63)

Chorioretinal Infection:

A) Viral Retinitis (These are more common in immunocompromised patients): Name four of these types of infections.

B) Parasitic Disease: Name two common ones

C) Bacterial Disease: Name two common ones


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a) HIV, CMV, ARN, PORN

Acronym Steeve: Syphilis, toxo, tubuerculosis, endogenous endopthalmitis, viral, etc (Pneumonic for DDx)
HIV (Acquired Immune Deficiency Syndrome): What is the most severe in a spectrum of immunodeficiency state caused by infection with the HIV? Infection with HIV is characterized predominantly by ____-_____ deficiency. Host CD4+ T lymphocytes are depleted through a combination of increased destruction and impaired thymic production. Impaired cellular immunity facilitates diseases associated with infectious agents, including both _______ and _______ that result from malignant transformation of infected cells.
AIDS
T-lymphocyte
Infections and neoplasms
HIV: AIDs requires a CD4 count less than 200 microliters; CD4 less than 14% of total lymphocytes; and occurrence of one or more of the specific group of opportunistic infection and neoplasms predictive of severe immunodeficiency. The "___ ____" test measure the amount of HIV RNA in the patient's blood using polymerase chain reaction. Viral load provides a highly significant indicator of the likelihood of progression to AIDS and ______. This test is used to monitor, _____ of HIV, guide the _______ for therapy, predict the future course and detect exposure to the virus.
Viral Load
Mortality Status
Recommendations
The CD4 cell count measures the number of CD4+ T-lymphocytes in the patient's blood. This provides a measures of the patient's what? HIV treatment guidelines recommend starting anti-HIV therapy when the CD4 cell count falls below _____ microliters. If untreated, HIV infection, the risk of AIDS diseases is small before the CD4 count has reached 200 cells/microliter.
a) Immune system
b) 350
T/F. HIV retinopathy is directly related to CD4 count.
True
HIV Treatment: Currently available drugs that act against HIV include reverse transcriptase inhibitors and protease inhibitors. These medications are known collectively as what? These drugs, by interrupting the infection cycle of HIV, allow a partial restoration of immune function and thereby resulted in a substantial decline in opportunistic infections.
HAART (Highly active antiretroviral therapy)
HIV Ophthalmic Manifestations: Important not only because of the morbidity associated with vision loss but because ophthalmic manifestations may indicate what? Noninfectious vasculopathies are like this disorder? Opportunistic infections include what three diseases? Neoplasms include kaposi sarcoma. Neuro-ophthalmic abnormalities include cranial nerve palsies. Drug-induced ocular side effects.
a) HIV retinopathy
b) CMV retinitis, ARN, Toxoplasmosis
HIV Retinopathy: _____ _____ abnormalities are the most common ocular findings reported in people with HIV infection (seen in about 40-60% of HIV-positive patients. HIV retinopathy is related to _____ ____ status. Asymptomatic HIV infected patients rarely have ______ apparent lesions, but nearly all degree of advanced AIDS have some degree of HIV retinopathy. May occur with CD4+ count >_____ cells/micron but prevalence of microvasculopathy is ______ proportional to CD4+ count

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a) Noninfectious Microvascular
b) Overall Immune
c) Clinically
d) 200
e) Inversely
HIV Retinopathy has many nonspecific findings such as CWS, hemorrhages, microaneurysms, white-centered hemorrhages (Roth spot), telangiectasias, and ischemic maculopathy. What is the most common finding in patients with HIV retinopathy? The cause of noninfectious microvasculopathy is unknown and likely multifactorial. Other causes of non-infectious microvasculopathy include ____ _____ or _______ should always be considered. Patients with both diseases may have a more severe version of this disease.
a) Cotton Wool Spots
b) Diabetes M or Hypertension
CMV: CMV is rare or nonexistent in the absence of immunosuppression. What is the most common intraocular infection in people with AIDS? It is rarely the first manifestation of AIDS. Most affected patients have counts of less than _____ cells/microliter at diagnosis. CMB is ubiquitis, DNA-containing ______ virus. Up to 90% of the general adult population develops a ______ to CMV. It is a neutrophic virus with tendency to infect neural tissues of the retina.

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a) CMV
b) 50
c) Herpes
d) Antibodies
CMV in the retina:
In the periphery it appears as what?
In the posterior pole it appears as what?
a) Dry (Granular)
b) Wet (Vasculitis, blood)
CMV Retinitis: Since the introduction of HAART only about _____% of HIV patients Develop CMV. The decline in frequency may not only reflect the widespread use of potent antiretroviral therapy but also the changing demographic of AIDS. Heterosexual men are less likely than homosexual men to develop CMV retinits, perhaps because homosexuals have higher rate of pre-existing CNV infection. CMV retinitis is often the presenting sign of what? All patients with CMV should have a thorough systemic evaluation.
5%
Systemic CMV
CMV Risk factors: CD4+ lymphocyte count of less than ____ cells/microliter Systemic CMV infection (85% of individuals with this developed CMV retinitis). High levels of HIV in the blood, High levels of CMV in the blood, homosexual activity as route of HIV infection.
50
CMV Retinitis: Vision is usually good at time of diagnosis. There is no pain or redness. Floaters and photopsias are common. Visual field defects are common. Over ______% of affected patients were asymptomatic at time of diagnosis. Screening is very important in AIDS patients where over half of the new cases o CMV are diagnosed during routine screening. Routine _______ examination of patients with cell count less than _______ microliters has been recommended.
a) 75%
b) BIO
c) 100
CMV Retinits: CMV is a slowly ___________, _____ retinitis that may affect the posterior pole, peripheral retina, or both and may be unilateral or bilateral. The disease is bilateral 30-40%f cases at diagnosis. Involved areas appears as _________ intraretinal lesions areas of infiltrate; and often necrosis, along with _______- arcades in the posterior pole. Prominent retinal hemorrhages are often seen within necrotic areas or along its leading edge. Peripherally, CMV retinitis tends to have a less intense white appearance with areas of ______ white retinitis that may or may not demonstrate associated retinal hemorrhages.
a) Progressive, necrotizing
b) White
c) Vascular
d) Granular
CMV Clinical Features: The characteristic lesion has a dry-appearing granular border surrounding and area of retinal edema and full-thickness retinal necrosis. There is a spectrum of lesion appearances.

a) ________ or _____type: Prominent necrosis and hemorrhage, often along blood vessels in posterior pole. Pizza Pie; Crumbled Cheese and Ketchub

b) ________ or ______ type: Most often found in the retinal periphery and has less dense retinal opacification and little or no hemorrhage.

c) Many cases of CMV have both types.
a) Fulminant or edematous
b) Indolent or granular type
CMV Clinical Features: Progression of retinitis generally occurs with a _____ ____ of active retinitis and a trailing region of thin ______ retina. This pattern indicates cell to cell transmission of the virus. As the retina progresses, an area of atrophic avascular retina may remain with underlying retinal pigment epithelial atrophy and/or hyperplasia.
a) Leading edge
b) Gliotic
CMV Clinical Features: What is common and may be widespread "frosted branch angilitis"? There are usually mild anterior chamber and vireous inflammatory reactions. Fine precipitates are common. Exudative retinal detachment. Optic atrophy may occur as a late manifestation secondary to widespread retinal destruction.
a) Perivascular sheathing
CMV Vision Loss: Left untreated, CMV can progress to loss of light perception. Vision loss may result from primary or secondary optic nerve involvement, retinal necrosis involving the central macula, rhegmatogenous retinal detachment, retinal vein or artery occlusion or serous macular exudation. Differential diagnosis includes retinitis, endophthalmitis, and intraocular lymphoma.

T/F. The distinction between these diseases is usually made clinically and additional work-up is usually unnecessary.
True
CMV Treatment: The mainstay of tx for exogenously immunosuppressed persons remains amelioration of immunosuppresion. Reduction of the immunosuppression results in ______ of the retinitis. HAART can lead to resolution of CMV retinitis even though it has no direct activity against CMV because it leads to reconstitution of the patient's immune system. It typically takes _____ months of a sustained elevation of CD4 count above 100 to cause healing of the retinitis.
a) Healing
b) 3
Anti-CMV Therapy: __________ is usually successful at controlling CMV infection, but has many side effects that may prevent concurrent use of HAART when given IV. May be given IV to reduce side effects. Valganciclovir has less effects and can be given orally. Foscarnet is an alternative for those unresponsive to ganciclovir.
Ganciclovir
CMV Complications RRD: Affects 25-33% of eyes with CMV retinitis per year. Most result from multiple, small, ill-defined ____ within the necrotic retina or at the junction of the necrotic and normal retina. Low success rate with conventional retinal detachment, surgical techniques. Pars plana vitrectomy with long term silicone oil tamponade has been considered. Final vision often decreased due to recurrent retinal detachment beneath the oil, corneal endotheial toxicity, ERM, or cataract.
a) Holes
CMV Complications (Immune Recovery Uveitis): Characterized by an increase in ______ ____ in eyes of patients with CMV, attributable to ______ _______. The most characteristic findings include prominent ______ __ and ____ ____ reactions. Other findings include optic disc edema, ERM, cystoid macular edema, and retinal _______. Is presumably an inflammatory response against retained viral _______ as the patient's immune system recovers.

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a) Intraocular inflammation
b) Immune reconstitution
c) Anterior Chamber
d) Vitreous humor
e) Neovascularization
f) Proteins
What is the leading cause of severe vision loss in people with AIDS and CMV retinits?

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Immune recovery uveitis
This is a necrotizing retinitis that is also characterized by prominent anterior uveitis, retinal and choroidal vasculitis, vitreitis, and papillitis.
a) Acute retinal necrosis syndrome
ARN: What is the most frequently identified cause of ARN (although HSV could also be a cause)? VZV or HSV in patients older than 25 years whereas HVS-2 causes ARN in patients younger than 25 years.
a) VZV (Zoster virus)
ARN Relation to HIV: Patients with AIDS and ARN syndrome usually have a CD4+ cell count higher than ____ cells/micron and a history of dermatomal ____ __ or HSV dermatitis. It occurs in up to 17% of HIV-infected patients following the development of HZV ophthalmicus. Is primarily seen in otherwise ________ persons but has been reported in immunocompromised people as well. A variant of this disease is known as what....ONLY SEEN IN AIDS PATIENTS.

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a) 60
b) Herpes Zoster
c) Healthy
d) PORN (progressive outer retinal necrosis)
ARN: Symptoms include progressive visual blurring in one or both eyes occurring over several weeks. Diffuse ocular ________ may cause severe ________ and ______. Prominent anterior uveitis and posterior uveitis. Retinitis is manifest by _______ of retina in periphery. May have vasculitis and hemorrhages.
a) Inflammation
b) Pain
c) Swelling
d) Opacification
ARN: Optic nerve inflammation includes optic neuropathy, which might be one of the first signs of ARN with subsequent development of other retinal manifestations. Days to weeks after onset of infection, the peripheral lesions usually coalesce into _____ or ______ _______ ring of necrotic retina. Desquamates into vitreous resulting in vitreous sheets.
a) White or yellow circumferential
ARN Syndrome Diagnosis: Is made __________. The required clinical criteria include one more foci of retinal necrosis with discrete borders in ________ retina. Rapid _____ of disease in the absence of therapy. ______ spread of disease. Evidence of ________ vasculopathy and arteriolar involvement. A prominent ______ reaction in the vitreous and anterior chamber

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a) Clinically
b) Peripheral
c) Progression
d) Circumferential
e) Occlusive
f) Inflammatory
ARN Treatment: _________ therapy is recommended. Oral steroids may diminish the generalized ocular inflammatory response and ON infiltration. Anticoagulants may help with vascular occlusions.
Acyclovir
ARN Complications: Up to 75% of ARN patients develop _____ _____ ______. Prophylactic laserplexy may be used around active retinitis.
RRD (Detachment)
Progressive Outer Retinal Necrosis: A variant of necrotizing _______ retinopathy that occurs in patients with advanced HIV. Usually caused by? Multifocal lesions, initial involvement of the ______ retina, _____ of vascular inflammation, minimal or no ______ inflammation, and EXTREMELY RAPID PROGRESSSION. It has a "_____ ___" perivascular pattern. Optic neuropathy occurs early.

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a) Herpetic
b) VZV (Zoster virus)
c) Outer, absence, vitreous
d) Cracked mud
PORN:Differentiated from other forms of retinitis based upon clinical presentation. Treatment is what? Prognosis is similar to ARN, RRD occurs in 70-85% of patients.
a) Systemic Antiviral Therapy
This is considered the most common cause of infection of the human retina (30-50%) of all posterior uveitis in North America

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Toxoplasmosis
Toxoplasmosis: One of the most common human infections throughout the world. Toxoplasma gondii is an obligate intracellular _________. After infecting a cell the organism rapidly proliferates, then forms cysts containing thousands of tachyzoites. The _______ is well tolerated by the host and provokes ______ inflammatory reactions. The organism continues to multiply within the cyst until it ruptures, which invades continugous cells

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a) Protozoan
b) Cyst
c) No
Toxoplasmosis Mode of transmission: ingestion of undercooked infected meat, ingestion of parasite my contaminated anything, blood transfusions, ________ transmission.
Transplacental
Toxoplasmosis: Can be divided into four clinical disorders: _______ Toxo, acquired toxo, _________ of ocular toxo, and toxo in immunocompromised.
Congenital
Reactivation
Congenital Toxo: Results from _______ transmission. Mother asymptomatic. The most common clinical manifestation is what?
a) Transplacental
b) Retinochoroiditis
Congenital Toxo: Involvement of the macular area is common in patients with congenital toxo. Lesion appearance can vary with punched-out scar with underlying sclera resulting from extensive retinal and choroidal necrosis surrounded by pigment proliferation. A conglomerate of proliferated retinal pigment cells. Appear as a small clump in the retina. Scar harbors what?
a) Toxo cysts
Ocular Toxoplasmosis: Most commonly presents as a focus of _______ retinitis involving ______ retinal layers and associated with white fluffy lesion surrounded by retinal _________. A retinal ______ may be present and appears as a yellowish mass surrounded by red reflex. Extensive and marked ______ reaction is common and may preclude visualization of retinal details. Typical "______ in _____ appearance.

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a) Necrotizing
b) Inner
c) Edema
d) Granuloma
e) Vitreous
f) Headlight in the fog
Ocular Toxo: Recurrent toxo retinitis frequently "________" or occurs adjacent to previous scar. Old inactive lesions often appear to be a conglomeration of previous multiple inflammatory foci. Small peripheral lesions usually subside spontaneously leaving behind small scars that do not cause significant vision loss
a) Satellites
Ocular Toxo: Observing the typical clinical picture of a focus of necrotizing satelliting to a pigmented chorioretinal scar, and by demonstrating a positive ______ of serum and by _____ _____ other causes of posterior uveitis and retinchoroiditis.
a) Titer
b) Ruling out
Ocular Toxo Treatment: There is no chemotherapeutic agent that is effective against the encysted form of the parasite (no _____ _____ can eradicate the infection). Acute toxo retinochoroidites is treated with a combination of ________ and _______. Oral or periocular steroids are added for vision threatened to minimize tissue damage and host defense.
a) Therapeutic agent
b) Pyrimethamine and Sulfadiazine
Ocular Toxo Prophylaxis: Should be considered in cases of recurrent toxo uveitis. Silveira examined effectiveness of Bactrim versus no prophylactic treatment for recurrent toxo. The Bacitrim group had fewer recurrences which suggests that _______ should be considered in recurrent cases.
Prophylaxis
Toxocariasis: In the U.S. approximately 10,000 cases are reported annually to the CDC. 5% in USA. Toxocariasis is caused by larvae of Toxocara canis in dogs, two ________ parasites of animals. Children are usually infected by ingesting _______ contaminated with eggs. In humans, ingested eggs mature in the small intestine and then migrate to other sites in the body where they elicit a _________ reaction. Lesions are usually found in liver, but also lung, heart, striated muscle, brain and eyes. Symptoms are caused by ______ of worms through the body causing fever, asthma, stomach pain, hepatomegaly and headaches.
a) Nemotode
b) Soil
c) Granulomatous
d) Movement
Toxocariaisis: Ocular infection is called "ocular larval migrans" occurs when the worm enters the eye commonly causing decreased vision, uveitis, and a subretinal __________ eventually leading to ______ scar. In early stages it may resemble a neoplasm which must be differentiated from retinoblastoma. Treatment includes steroids, antihelminthics and surgery.
a) Granuloma
b) Chorioretinal
Tuberculosis: Is an infectious disease caused by a ______ that produces ______ _____. It is spread how? primary infection occurs following initial exposure, and then the disease enters a latent phase until reactivation occurs during times of immuno-compromise. Approximately 1/3 of the world's population in infected with TB. It is second only to HIV/AIDs as a cause of ________ from infectious disease. Co-infection of TB with HIV may be important risk factor for activation of TB. Only ____% of infected individuals develop the symptomatic disease. The majority of manifestations are __________. The infection spreads via bloodstream to nearly all organs of the body. What are the two most common techniques for detecting TB ? TB is a notifiable disease in US where it must be reported to CDC.
a) Bactera, caseating granulomas
b) Direct human contact
c) Death
d) 10%
e) Pulmonary
f) PPD and Mantoux test
Ocular TB: Approximately 2% of patients have ocular manifestations. The ocular manifestations of TB result from either active _________ or an _______ reaction to organism. What is the most common ocular manifestation? TB uveitis can include any variation of ________, _______, or _____ uveitis. In the posterior segment, TB may manifest as _______ ____ or _____, subretinal abscess, _______ choroiditis, or retinal vasculitis.

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a) Infection; immunologic
b) Uveitis
c) Anterior, intermediate, posterior
d) choroidal tubercles or tuberculomas
e) Serpinginous
Tuberculosis (Choroidal Tubercles): Characterized by deep, multiple, discrete yellowish __________ between 0.5-3.0 mm in diameter, numbering 5 to several hundred. Located predominately in the posterior pole and may be accompanied by disc edema, nerve fiber layer hemorrhages, and varying degrees of vitritis and granulomatous anterior uveitis. May also present as a single, focal, large, elevated choroidal mass (________). Other choroidal manifesteations include multiple choroiditis and serpinginous-like choroiditis.
a) Granulomas
b) Tuberculoma
Tuberculosis (Retinal Vasculitis): Associated with vitritis and sometimes neuroretinitis. Periphlebitis with capillary non-perfusion often leads to nonpurfusion often leads to neo, vitreous hemorrhage and detachment. TB has been detected by PCR in the vitreous of patients with ________ disease.
Earle's
*Tuberculosis Diagnosis:
a) Confirmed ocular TB: ______ features and direct ____ or _______
b) Presumed ocular TB: ______ features, with a ______ test including ______ test, a lesion on _______ or evidence of active _______ TB.
c) Presumed TB: clinical features with exclusion of other uveitic entities and a positive therapeutic trial of anti-TB*

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a) Clinical, culture or stain
b) Clinical, positive, skin, Chest X-ray, extrapulmonary
Tuberculosis: Systemic Anti-AB treatment should be initiated by an infectious disease specialist.
Note
This is a sexually transmitted disease caused by spirochete bacterium Treponema pallidum. Congenital version is contracted in utero.
Syphilis
Syphilis: A primary skin lesion known as _____ is followed by 3 weeks to 6 months later by hematogenous dissemination of the organism, a stage known as secondary syphilis.
Chancre
Syphilis: Secondary disease manifestations are broad and __________ ranging from a rash to general malaise, fever, and painless lymphadenopathy. Late sequelae involving ________ _______ system, the aorta, and soft tumor like areas of inflammation known as gummas are referred to tertiary stage.
a) Nonspecific
b) Central nervous system
Syphilis: Ocular involvement may occur in which stage of syphilis? Which part of the eye does it affect? The clinical presentation is so varied, ocular syphilis has been classically regarded as what? Should be considered as a DDX in any cause of what? There is such a high rate of tertiary syphilis in patients with ocular involvement that the CDC recommends a _ ___ for all patients with ocular inovlvement

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a) Any stage
b) Any part
c) Great imitator
d) Uveitis
e) Lumbar Punture
Syphilis: Congenital has a salt and pepper appearane. Inner retinitis includes white spots. Acute posterior has placoid yellowish lesions. And neuroretinitis incudes inflammation of optic nerve.
Note
*Diagnosis requires a high index of suspicion because of the varied manifestatins of the disease.

a) Nontreponemal (Screening): Detects ________ to cardioplin cholesterol antigen). What are these two tests?

b) Treponemal Tests (Confirmatory): Confirms a positive result on screening test. What test is this?

c) Treatment is what? *

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a) Antibodies; VDRL (venereal disease research laboratory) and Rapid plasma reagin (RPR)

b) Fluorescent treponemal antibody absorption test (FTA-ABS)

c) Penicillin
Differential Diagnosis of Viral Retinitis: ARN

a) Immune status?
b) Laterality: Bilateral or unilateral?
c) Visual Loss: Mild, Mod, Severe?
d) Vitreous Reaction?
e) Retinal Involvement: Full thickness or outer retinal involvement?
f) Classic appearance?
g) Vasculitis: Common or uncommon?
h) Retinal hemorrhages: Common or uncommon?
i) Retinal Detachment: Common or uncommon?
j) Progression: Rapid or slow?
a) Healthy
b) Bilateral
c) Severe
d) Vitritis (Significant)
e) Full thickness
f) Swiss cheese
g) Common
h) Common
i) Common
j) Common
k) Rapid
Differential Diagnosis of Viral Retinitis: Progressive outer retinal necrosis

a) Immune status?
b) Laterality: Bilateral or unilateral?
c) Visual Loss: Mild, Mod, Severe?
d) Vitreous Reaction?
e) Retinal Involvement: Full thickness or outer retinal involvement?
f) Classic appearance?
g) Vasculitis: Common or uncommon?
h) Retinal hemorrhages: Common or uncommon?
i) Retinal Detachment: Common or uncommon?
j) Progression: Rapid or slow?
a) Immunosuppressed
b) Bilateral
c) Early loss
d) Minimal, none
e) Deep outer retina
f) Cracked mud
g) uncommon
h) uncommon
i) common
j) Rapid
Differential Diagnosis of CMV:

a) Immune status?
b) Laterality: Bilateral or unilateral?
c) Visual Loss: Mild, Mod, Severe?
d) Vitreous Reaction?
e) Retinal Involvement: Full thickness or outer retinal involvement?
f) Classic appearance?
g) Vasculitis: Common or uncommon?
h) Retinal hemorrhages: Common or uncommon?
i) Retinal Detachment: Common or uncommon?
j) Progression: Rapid or slow?
a) Immunocompromised
b) Bilateral
c) Only if macula affected
d) None
e) Full thickness
f) Pizza Pie
g) Seen, uncommon
h) Common
i) Less common
j) Slow
Note that all three have anterior uveitis present (mild).
Note
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