Multimodal Imaging of Punctate Outer Retinal Toxoplasmosis

We present multimodal imaging of a unique case of ocular toxoplasmosis in a young girl, marked by recurring macular lesions despite treatment and prophylaxis, progressing unusually to punctate outer retinal toxoplasmosis. An eleven-year-old girl, without significant medical history, presented with blurred vision and floaters. Initial assessment showed active macular chorioretinitis in her left eye, inactive scarring in her right eye, and positive IgG but negative IgM toxoplasmosis serologies. Treatment included intravitreal clindamycin, oral azithromycin, and prednisone for her right eye, followed by trimethoprim/sulfamethoxazole (TMP-SMX) prophylaxis. Recurrence in the right eye led to retreatment with clindamycin and TMP-SMX. Recurrences continued and punctiform gray-white lesions in her right eye's retina appeared. These were localized into the outer nuclear layer on OCT with signal hypertransmission and were hypoautofluorescent. Low immunoglobulin levels were identified, suggesting that conventional treatment and prophylaxis might be inadequate in patients with hypogammaglobulinemia.