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Choroiditis and exudative macular detachments in a post transplant leukaemic patient: an unusual presentation of Pneumocystis jiroveci infection
  1. K Sabri,
  2. K Bibby
  1. Department of Ophthalmology, Leicester Royal Infirmary, Leicester LE1 5WW, UK
  1. Correspondence to: K Sabri Department of Ophthalmology, Leicester Royal Infirmary, Leicester LE1 5WW, UK; ksabri{at}yahoo.com

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Pneumocystis jiroveci is a commensal found in the respiratory tract of healthy individuals. It can cause infections of almost any organ in immunocompromised hosts. P jiroveci choroiditis, featuring multifocal choroidal lesions, has been reported in immunocompromised patients despite prophylactic use of inhaled pentamidine. We report a post-transplant leukaemic patient whose posterior segment findings demonstrate an atypical picture of recurrent P jiroveci choroiditis.

Case report

A 20 year old woman presented with a 1 week history of bilateral blurred vision, dyspnoea, and dry cough. Visual acuity was reduced to 6/36 bilaterally with posterior subcapsular cataracts. Funduscopy disclosed multifocal, creamy-yellow choroidal lesions at both posterior poles with exudative retinal detachments at the maculae (fig 1). Optic discs and retinal vessels were normal. Fluorescein angiography showed early patchy hypofluorescence (corresponding to the choroidal lesions) and late hyperfluorescence with pooling beneath the detachments.

Figure 1

 Multifocal, creamy-yellow choroidal lesions at both posterior poles with massive exudative retinal detachments at the maculae.

Three years earlier she had undergone a successful allogeneic bone marrow transplant for chronic myeloid leukaemia. Her maintenance therapy included inhaled pentamidine as prophylaxis against P jiroveci infection. However, she admitted to not taking her inhaled pentamidine. Molecular genetic and radiological investigations excluded leukaemic recurrence. Chest x ray showed left lung shadowing and bronchoalveolar lavage isolated P jiroveci. P jiroveci pneumonia with P jiroveci choroiditis was diagnosed and high dose oral co-trimoxazole 7.2 g/day (120 mg/kg/day) and prednisolone 60 mg/day commenced. Within 2 weeks her respiratory and ocular symptoms improved. Visual acuities returned to 6/9 and the fundal appearances resolved. She was discharged on daily oral co-trimoxazole 960 mg, prednisolone 20 mg, and inhaled pentamidine.

Three weeks later she was readmitted with increasing dyspnoea and blurred vision. Chest x ray and computed tomography findings were compatible with diffuse interstitial fibrosis in both lungs. Funduscopy revealed peripapillary choroidal lesions with disc swelling bilaterally (fig 2). This time the choroidal lesions were peripapillary only rather than throughout the posterior pole, with exudative detachments inferiorly. Recurrent P jiroveci pneumonia and choroiditis was diagnosed and oral atovaqoune and high dose prednisolone were commenced. Within 3 weeks her fundal appearance resolved leaving only some pigmentary changes. Her discharge medication included daily oral prednisolone 40 mg, co-trimoxazole 960 mg, and inhaled pentamidine. There have been no further intraocular recurrences.

Figure 2

 peripapillary choroidal lesions with disc swelling.

Comment

Pneumocystis jiroveci is a commensal, found in the respiratory tract of healthy individuals. It can cause infections of almost any organ in immunocompromised hosts.1–3P jiroveci choroiditis has been reported in immunocompromised patients despite prophylactic use of inhaled pentamidine.4,5 The diagnosis is based on the clinical findings of multifocal yellowish circular choroidal lesions at the posterior pole. P jiroveci has been found in these lesions on histological sections3,5 and the lesions resolve on systemic anti-pneumocystis treatment.4 However, most cases of P jiroveci choroiditis are diagnosed histologically post mortem.3,6

Thus, the acute clinical findings may be more varied than previously described. In our patient, massive exudative retinal detachments were associated with the previously described choroidal lesions. The clinical picture varied on the second presentation, but there was complete and rapid resolution of the signs with anti-pneumocystis therapy. To the best of our knowledge, this is the first report of P jiroveci choroiditis causing exudative retinal detachments. P jiroveci should be considered in the differential diagnosis of susceptible patients, even if the ophthalmological findings are “atypical.”

References

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