How is toxoplasma retinochoroiditis in HIV infection treated?

Answer

Although small, peripheral chorioretinal lesions can be monitored in the immunocompetent patient, immunocompromised hosts with active lesions should be treated regardless of disease extent.

For active chorioretinitis within 2-3 mm of the disc or fovea, which threatens vision, or peripheral lesion associated with severe vitritis, therapy is continued for 3-6 weeks. First-line regimen is as follows: (1) pyrimethamine 75 mg PO load, 25 mg PO twice daily, plus, (2) folinic acid 3-5 mg PO twice weekly (to reduce the adverse effect of bone marrow toxicity of pyrimethamine), and (3) sulfadiazine 2 g PO load, then 1 g PO 4 times daily.

Clindamycin 300 mg PO 4 times daily may be used alone (if the patient is allergic to sulfa drugs) or in combination with sulfadiazine as alternative treatment. Patients on clindamycin should be monitored for the possible adverse effect of pseudomembranous colitis. Other alternative therapeutic regimens trimethoprim/sulfamethoxazole (160 mg/800 mg) 1 tablet PO twice daily, with or without clindamycin.

Platelet count and CBC should be monitored once to twice weekly for patients on pyrimethamine. If the platelet count falls below 100,000, then a reduction in the dose along with an increase in the dose of folinic acid should be initiated. It is important that patients on pyrimethamine avoid taking vitamins containing folic acid.

Retinal laser photocoagulation, cryotherapy, and vitrectomy have been used as adjunct therapy in the treatment of ocular toxoplasmosis.

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Luca Rosignoli, MD Resident Physician, Department of Ophthalmology, University of Texas Health Science Center at San Antonio, Joe R and Teresa Lozano Long School of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Leen Saad Azeez, MS MD Candidate, UT Health San Antonio Long School of Medicine

Disclosure: Nothing to disclose.

Jeong-Hyeon Sohn, MD Associate Professor of Ophthalmology, Chief, Retina Division, Director, Surgical Retina and Vitreous Fellowship Program, University of Texas Health Science Center at San Antonio, Joe R and Teresa Lozano Long School of Medicine; Medical Director, TDI Ophthalmology Clinic, Department of Ophthalmology, UT Health San Antonio

Jeong-Hyeon Sohn, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Retina Specialists, American Uveitis Society, Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

R Christopher Walton, MD Adjunct Professor, Department of Ophthalmology, University of Texas Health Science Center at San Antonio

R Christopher Walton, MD is a member of the following medical societies: American Academy of Ophthalmology, American Uveitis Society

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Chief Editor

Andrew A Dahl, MD, FACS Assistant Professor of Surgery (Ophthalmology), New York College of Medicine (NYCOM); Director of Residency Ophthalmology Training, The Institute for Family Health and Mid-Hudson Family Practice Residency Program; Staff Ophthalmologist, Telluride Medical Center

Andrew A Dahl, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Intraocular Lens Society, American Medical Association, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Medical Society of the State of New York, New York State Ophthalmological Society, Outpatient Ophthalmic Surgery Society

Disclosure: Nothing to disclose.

Additional Contributors

Robert A Copeland, Jr, MD † Chair, Professor, Department of Ophthalmology, Howard University College of Medicine

Robert A Copeland, Jr, MD is a member of the following medical societies: American Academy of Ophthalmology

Disclosure: Nothing to disclose.

Brian A Phillpotts, MD Ophthalmologist, St Luke's Cataract and Laser Institute

Brian A Phillpotts, MD is a member of the following medical societies: American Academy of Ophthalmology, American Diabetes Association, American Society of Retina Specialists, Association for Research in Vision and Ophthalmology, Association of University Professors of Ophthalmology

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