ACUTE MYOCARDITIS WITH CARDIOGENIC SHOCK AND MULTIPLE ORGAN FAILURE, FOLLOWED BY BILATERAL PANUVEITIS MASQUERADING AS ENDOGENOUS ENDOPHTHALMITIS, DUE TO TOXOPLASMA GONDII IN AN IMMUNOCOMPETENT PATIENT.

PURPOSE: To report a case of systemic and ocular toxoplasmosis in an immunocompetent patient, who developed myocarditis with resulting cardiogenic shock and multiple organ failure, followed by bilateral panuveitis masquerading as endogenous endophthalmitis. METHODS: Single case report with images. RESULTS: A 59-year-old man with a history of monoclonal gammopathy of undetermined significance and associated scleromyxedema but otherwise immunocompetent was admitted to the intensive care unit for cardiogenic shock and multiple organ failure due to presumed viral myocarditis. After hospital discharge, ophthalmic examination revealed what seemed to be endogenous fungal endophthalmitis in both eyes. The ocular inflammation failed to improve on local and systemic antifungal therapies. After repeated testing and vitrectomy, the causative organism responsible for his intraocular inflammation remained elusive. The patient was then found to have significantly elevated serum titers of anti-Toxoplasma gondii IgG and IgM, followed by an appearance of a focal retinochoroidal lesion more typical of ocular toxoplasmosis. Systemic anti-Toxoplasma therapy led to resolution of intraocular inflammation, and the patient had since fully recovered from the myocarditis and its multiple comorbidities. Of note, myocardial biopsy and polymerase chain reaction testing of aqueous and vitreous fluids were all negative for Toxoplasma. CONCLUSION: Even in an immunocompetent patient, Toxoplasma can result in myocarditis with significant morbidities and even death, and its ocular manifestation may be quite different from the classic focal retinochoroiditis. In addition, polymerase chain reaction analysis of ocular fluids can be unreliable in an immunocompetent host, and thus treatment decision should be guided by clinical history and examination findings.

Combined Central Retinal Vein and Branch Retinal Artery Occlusion Post Intense Physical Activity.

We report a case of combined central retinal vein occlusion and branch retinal artery occlusion. A previously healthy 47-year-old male presented with decreased vision in the right eye after completing a half marathon. A fundus exam and retinal imaging revealed a combined central retinal vein and branch retinal artery occlusion. In the present report, we review the literature and discuss the possible mechanisms behind combined retinal vessel occlusions. To our knowledge, this is the first reported case of combined central retinal vein occlusion and branch retinal artery occlusion following intense exercise.

Chronic Traumatic Giant Macular Hole Repair with Autologous Platelets.

We report on the closure of a chronic posttraumatic giant macular hole. The patient presented with decreased vision in the left eye following blunt trauma 20 years prior. His dilated fundus examination revealed a 3000 um base-diameter full thickness macular hole. Surgical repair was performed with pars plana vitrectomy (PPV), internal limiting membrane peeling and autologous platelet concentrate (APC) injected over the macular hole. At one month follow-up, the macular hole had closed on exam and optical coherence tomography (OCT), and the patient reported subjective visual improvement. To our knowledge, this report presents the first case of a chronic giant macular hole successfully closed after undergoing surgery with adjuvant platelets therapy.

Microsporidial Stromal Keratitis: Successful Treatment with Topical Voriconazole and Oral Itraconazole.

We report a case of microsporidial stromal keratitis successfully treated with topical voriconazole and oral itraconazole. A 30-year-old Hispanic male construction worker who wears contacts lenses presented with left eye erythematous, epiphora, and mild pain increasing over few days after failing previous antibiotics treatment. His best corrected visual acuity in the left eye was count fingers at three feet, and the slit lamp examination showed 3+ conjunctival injection, a circular central corneal ulcer 3.2 mm in diameter, stromal thinning, and an anterior chamber with white cells, flair, and 0.1 mm hypopyon. A cornea punch biopsy identified microsporidial organisms with some features suggestive of Vittaforma corneae. After treatment with topical voriconazole and oral itraconazole for eight weeks, the patient had complete resolution with no recurrence for over 12 months of follow-up. To our knowledge, this is the first reported case of successful treatment of microsporidial stromal keratitis with antifungals.

Modulation of single-cell IgG secretion frequency and rates in human memory B cells by CpG DNA, CD40L, IL-21, and cell division.

During the recall response by CD27(+) IgG class-switched human memory B cells, total IgG secreted is a function of the following: 1) the number of IgG-secreting cells (IgG-SC), and 2) the secretion rate of each cell. In this study, we report the quantitative ELISPOT method for simultaneous estimation of single-cell IgG secretion rates and secreting cell frequencies in human B cell populations. We found that CD27(+) IgM(-) memory B cells activated with CpG and cytokines had considerable heterogeneity in the IgG secretion rates, with two major secretion rate subpopulations. BCR cross-linking reduced the frequency of cells with high per-cell IgG secretion rates, with a parallel decrease in CD27(high) B cell blasts. Increased cell death may account for the BCR-stimulated reduction in high-rate IgG-SC CD27(high) B cell blasts. In contrast, the addition of IL-21 to CD40L plus IL-4-activated human memory B cells induced a high-rate IgG-SC population in B cells with otherwise low per-cell IgG secretion rates. The profiles of human B cell IgG secretion rates followed the same biphasic distribution and range irrespective of division class. This, along with the presence of non-IgG-producing, dividing B cells in CpG plus cytokine-activated B memory B cell populations, is suggestive of an on/off switch regulating IgG secretion. Finally, these data support a mixture model of IgG secretion in which IgG secreted over time is modulated by the frequency of IgG-SC and the distribution of their IgG secretion rates.