1. Paulo Silva Guerra, Margarida Miranda, Joana Couceiro, Walter Rodrigues, M. Monteiro Grillo Ophthalmology Department - Hospital de Santa Maria. Director: Prof. Dr. M. Monteiro Grillo FINANCIAL DISCLOSURES The authors do not have any financial disclosure

2. Introduction Toxoplasma gondii is recognized as an important cause of ocular disease in humans. 6 Atypical lesions are seen in immunodeficiency due to various causes and also in elderly individuals. 4 In immunodeficient patients, ocular toxoplasmosis constitutes a diagnostic and therapeutic challenge. To report 3 cases of atypical toxoplasma retinochoroiditis in HIV positive patients, highlighting the need of systemic evaluation in the initial diagnosis, which in these cases lead to the diagnosis of HIV infection. Purpose:

3. Material & Methods Retrospective analysis of 3 patients from Uveitis Department with panuveitis and sudden loss of visual acuity and vitreous floaters (HIV infection already known in one case). All patients were submitted to complete ophthalmic examination and etiologic and systemic investigation.

4. CASE 1 ♀, 35 years, presented with sudden visual loss and vitreous floaters in the left eye LVA at presentation:<0,1 Etiologic and systemic investigation: IgM- IgG+ (Toxoplasma) Aqueous PCR: T. gondii + Ac HIV 1+ CD4+: 417 cel/µL After treatment: LVA - 0,1 RE - Normal LE - Extensive old pigmented scar, active retinochoroidal inflammatory focus, vitritis

5. CASE 2 ♂, 29 years, presented with bilateral progressive loss of vision with 1,5 years of duration. Bilateral VA at presentation: <0,1 Etiologic and systemic investigation: IgM- IgG+ (Toxoplasma) Aqueous PCR: Negative Ac HIV 2+, CD4+: 255 cel/µL Chronic Hepatitis B After treatment bilateral VA <0,1 Bilateral, multiple, retinochoroidal inflammatory lesions Several old pigmented scars Bilateral vitritis Bilateral cicatricial macular changes

6. CASE 3 ♂, 26 years (drug addict) HIV1+ (diagnosed 3 months before) LVA at presentation: 0,1 Etiologic and systemic investigation: IgM- IgG+ (Toxoplasma) Aqueous PCR: T. gondii + HCV + CD4+: 42 cel/µL After treatment: LVA - 0,4 LE: Extensive, active retinochoroidal inflammatory focus with a parapapillary location Tilted disc No satellite lesion

7. Conclusions In HIV positive patients ocular toxoplasmosis can assume atypical features. In the presence of toxoplasma retinitis and in atypical presentations the screening for immunodeficiency is mandatory, especially HIV infection. Aqueous fluid PCR is an important test to confirm the diagnosis, particularly in immunosuppressed patients where the clinical presentation assumes greater variability. References: 1. Elkins BS, Holland GN, Opremcak EM, Dunn JP, Jabs DA, Johnston WH et al. Ocular toxoplasmosis misdiagnosed as cytomegalovirus retinopathy in immunocompromised patients. Ophthalmology. 1994 Mar; 101(3): 499-507. 2. Moorthy RS, Smith RE, Rao NA. Progressive ocular toxoplasmosis in patients with acquired immunodeficiency syndrome. Am J Ophthalmol. 1993 Jun 15; 115(6):742-7. 3. Rothova A, de Boer JH, Ten Dam-van Loon NH, Postma G, de Visser L, Zuurveen SJ et al. Usefulness of aqueous humor analysis for the diagnosis of posterior uveitis. Ophthalmology. 2008 Feb; 115 (2): 306-11. 4. Fardeau C, Romand S, Rao NA, Cassoux N, Bettembourg O, Thullez P et al. Diagnosis of toxoplasmic retinochoroiditis with atypical clinical features. Am J Ophthalmol. 2002 Aug; 134 (2):196-203. 5. Gilbert RE, See SE, Jones LV, Stanford MS. Antibiotics versus control for toxoplasma retinochoroiditis. Cochrane Database Syst Rev. 2002 ;(1): CD002218. 6. Holland GN. Ocular toxoplasmosis: a global reassessment. Part I: epidemiology and course of disease. Am J Ophthalmol. 2003 Dec;136(6):973-88. 7. Holland GN. Ocular toxoplasmosis: a global reassessment. Part II: disease manifestations and management. Am J Ophthalmol. 2004 Jan; 137(1):1-17. 8. Westeneng AC, Rothova A, de Boer JH, de Groot-Mijnes JD. Infectious uveitisin immunocompromised patients and the diagnostic value of polymerase chain reaction and Goldmann-Witmer coefficient in aqueous analysis. Am J Ophthalmol. 2007 Nov;144(5): 781-5