Diagnostic dilemma- choroidal granuloma as an atypical rare presentation: A case report

Abstract

Purpose: To report a rare atypical case of ocular toxoplasmosis presenting as choroidal granuloma in a young adult. Case presentation: A 16-year-old male presented with sudden diminution of vision in the right eye. The visual acuity was 6/12p in the right eye. The anterior segment examination was normal. No relative afferent pupillary defect was present. The fundus examination of the right eye showed grade 1 vitritis, a normal disc with a well circumscribed active choroidal lesion on the posterior pole, inferior to the fovea along with surrounding Subretinal Fluid (SRF) pocket. The Optical Coherence Tomography (OCT) of the right eye showed choroidal elevation with the highest dimension just inferior to the fovea, along with surrounding SRF at the fovea. Fluorescein angiography showed punctate hyperfluorescent leakage points around the lesion. Intervention: Blood hemogram was normal with a raised erythrocyte sedimentation rate. Serological screening was positive for toxoplasmosis (IgM and IgG antibodies). Human Immunodeficiency Virus (HIV) and tuberculosis (QuantiFERON Gold test) were negative. Oral medications spiramycin 500 mg three times a day for 3 weeks along with folic acid once a day was started after paediatrician consult. Result: Follow up at 1 week, the visual acuity improved to 6/9 and the choroidal elevation along with the SRF was resolving on the OCT scan. After 3 weeks of treatment the visual acuity improved to 6/6 and the fundus showed complete resolution of the choroidal granuloma along with the surrounding SRF with no residual chorioretinal scar formation. Conclusions: Our case reports a rare atypical presentation of ocular toxoplasmosis with only one more case available in the literature of ocular toxoplasmosis presenting as a posterior pole choroidal granuloma. Timely intervention lead to complete resolution of the lesion and complete restoration of the visual acuity.