eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Chorioretinitis: Differential Diagnoses & Workup
Updated: Oct 16, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
Other Problems to Be Considered
Baylisascariasis
West Nile virus
Flavivirus
Workup
Laboratory Studies
- Routine laboratory screening in chorioretinitis (CR)
- CBC count and platelet count: Depression of all 3 lines (ie, erythrocytes, white cells, platelets) implies an infection that causes bone marrow suppression, which may be seen with congenital infections. Platelet count can be low in patients with some viral infections or intravascular coagulation.
- Liver function test: Measure alanine aminotransferase, aspartate aminotransferase, gamma-glutamyltransferase, alkaline phosphatase, bilirubin (total, direct, and indirect), albumin, and total protein levels. Also obtain activated partial thromboplastin time and prothrombin time. All or some of these measurements can be abnormal in most congenital infections.
- Renal function test: Assess creatinine and BUN levels. Urinalysis can be helpful in the detection of hematuria or casts.
- Etiology
- Herpes simplex virus (HSV) types I and II, Epstein-Barr virus (EBV), varicella, and human immunodeficiency virus (HIV) are elicited by cultures or polymerase chain reaction (PCR) of blood, cerebrospinal fluid (CSF), or tissues. Immunoglobulin titers (immunoglobulin [Ig]G) from CNS fluid, serum, and other body fluids (particularly in a newborn) are of uncertain value, except for screening purpose in HIV vertical infection, toxoplasmosis, and West Nile virus infection. Positive values in a newborn may represent passive transfer of maternal antibody.
- Congenital rubella can infect infants of nonimmune individuals and is diagnosed by interpreting results of viral culture and IgM and IgG titers in both infants and mothers.
- Cytomegalovirus (CMV) is shed in the urine of infants who are congenitally infected, and diagnosis is indicated by positive urine culture results in infants younger than 3 weeks. In immunodeficient hosts, a CMV antigenemia test using a peripheral blood sample is helpful in establishing recurrence or infection. The CMV antigenemia uses immunofluorescent assay on buffy coat polymorphonuclear cells to detect CMV-infected cells. CMV-PCR is also being increasingly used, although at the present time its interpretation in congenital infection remains unclear.
- Toxoplasma species are detected by specific IgA, IgM, IgG, Sabin-Feldman dye test, and PCR. Document Toxoplasma status of pregnant women and individuals who are immunocompromised.
- Lyme disease is detected by using PCR assay of CSF and serum. The presence of specific IgM and IgG on Western blot result of serum may be significant for diagnosis and staging of infection.
- Yersinia species are detected by special stool culture and acute and convalescent IgG titers.
- Syphilis is detected by using serology tests (eg, nontreponemal rapid plasma reagent, Venereal Disease Research Laboratory test in CSF) and specific treponemal tests (eg, fluorescein treponemal antibody absorption, microhemagglutination-Treponema pallidum).
- Mantoux skin test, acid-fast stain, and cultures of bronchial washings or biopsy samples of tissues detect M tuberculosis (MTB). MTB-PCR is available in many reference laboratories to detect the presence of MTB from biopsy and tissue samples, blood, and CSF. The quantiferon tuberculosis (TB) test, which measures lymphocyte interferon response to TB antigen, may aid in the diagnosis of TB.
- Toxocariasis serology can be tested by using an enzyme-linked immunoabsorbent assay (ELISA) and confirmed by using a specific Western blot (available from the Centers for Disease Control and Prevention [CDC]).
- Several serology tests for catscratch disease have been developed, including indirect immunofluorescent antibody (IFA) testing, which shows good correlation with strict clinical criteria. Demonstration of rising IgG titer provides the best evidence of infection.
- Baylisascaris tests can be performed using serum and CSF. ELISA and Western blot are available from the Department of Veterinary Pathobiology at Purdue University.
- Other studies
- Nitroblue tetrazolium test (or flow cytometry with dihydrorhodamine) is used to detect chronic granulomatous disease (CGD). In a healthy host, 95% or more of neutrophils produce superoxide radicals. In a host with a typical X-linked CGD, fewer than 5% of neutrophils have such ability.
- Vertical HIV infection is suggested by hypergammaglobulinemia and a depressed CD4+ T-cell count. An HIV DNA PCR of the newborn can be used to confirm diagnosis of HIV infection in the presence of maternal antibodies. Testing with DNA PCR should be done when the infant is aged 2 weeks, 1 month, and 4 months in all infants at risk for vertical HIV infection.
Imaging Studies
- Perform sonography, CT scanning, and/or MRI of the CNS or specific organs in patients in whom congenital infections are suspected or in an immunocompromised host.
- Perform chest radiography, CT scanning, or both in patients in whom TB or sarcoidosis is suspected. CT scanning is helpful in identifying sites on which to perform biopsy for diagnostic purposes.
- Perform CT scanning of the abdomen for hepatic or splenic dissemination of disease.
- Perform radiography or bone scanning of the skeleton in patients in whom syphilis is suspected.
- Perform echocardiography in patients with congenital rubella infection.
Other Tests
- Perform a skin biopsy for rare cases of dermal hematopoiesis (blueberry muffin infant syndrome) in patients in whom congenital CMV or congenital toxoplasmosis (CTP) is suspected.
Histologic Findings
- Chorioretinitis is usually diagnosed using ophthalmologic examination and not using histologic findings of the retina. However, evidence of lymphocytic infiltrations and exudates characteristic of vasculitis is found in many sites.
- Granulomatous changes can be evident in biopsy samples of lymph nodes, liver, or spleen in histoplasmosis, sarcoidosis, and tuberculosis. Fungal elements are rarely found in biopsy or postmortem samples.
More on Chorioretinitis |
| Overview: Chorioretinitis |
 Differential Diagnoses & Workup: Chorioretinitis |
| Treatment & Medication: Chorioretinitis |
| Follow-up: Chorioretinitis |
| Multimedia: Chorioretinitis |
| References |
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References
Koevary SB. Ocular involvement in patients infected by the West Nile virus. Optometry. Oct 2005;76(10):609-12. [Medline].
Zinkernagel MS, Bolinger B, Krebs P, Onder L, Miller S, Ludewig B. Immunopathological basis of lymphocytic choriomeningitis virus-induced chorioretinitis and keratitis. J Virol. Jan 2009;83(1):159-66. [Medline].
Stagno S, Britt W, et al. Cytomegalovirus Infections. In: Remington J, Klein J, Wilson C, eds. Infectious Diseases of the Fetus and Newborn Infant. 6th ed. Philadelphia, PA: Elsevier; 2006:739-81.
Hall BR, Oliver GE, Wilkinson M. A presentation of longstanding toxoplasmosis chorioretinitis. Optometry. Jan 2009;80(1):23-8. [Medline].
Wise ME, Sorvillo FJ, Shafir SC, Ash LR, Berlin OG. Severe and fatal central nervous system disease in humans caused by Baylisascaris procyonis, the common roundworm of raccoons: a review of current literature. Microbes Infect. Feb 2005;7(2):317-23. [Medline].
Egli A, Bergamin O, Mullhaupt B, et al. Cytomegalovirus-associated chorioretinitis after liver transplantation: case report and review of the literature. Transpl Infect Dis. Feb 2008;10(1):27-43. [Medline].
Greydanus DE, Noble KG, Hofmann AD. Chorioretinitis in the adolescent: two case presentations with discussion. Pediatrics. Dec 1977;60(6):884-92. [Medline].
Nassetta L, Kimberlin D, Whitley R. Treatment of congenital cytomegalovirus infection: implications for future therapeutic strategies. J Antimicrob Chemother. May 2009;63(5):862-7. [Medline].
Lopez A, Dietz VJ, Wilson M, Navin TR, Jones JL. Preventing congenital toxoplasmosis. MMWR Recomm Rep. Mar 31 2000;49:59-68. [Medline].
Elsheikha HM. Congenital toxoplasmosis: priorities for further health promotion action. Public Health. Apr 2008;122(4):335-53. [Medline].
Rothova A. Ocular manifestations of toxoplasmosis. Curr Opin Ophthalmol. Dec 2003;14(6):384-8. [Medline].
Freeman K, Tan HK, Prusa A, et al. Predictors of retinochoroiditis in children with congenital toxoplasmosis: European, prospective cohort study. Pediatrics. May 2008;121(5):e1215-22. [Medline].
Toxocariasis. CDC; accessed July 17, 2009. [Full Text].
Woods CR. Congenital syphilis-persisting pestilence. Pediatr Infect Dis J. Jun 2009;28(6):536-7. [Medline].
[Guideline] New York State Department of Health. Ophthalmologic complications of HIV infection. New York (NY): New York State Department of Health; 2004 Jan.
Reed JB, Scales DK, Wong MT, Lattuada CP Jr, Dolan MJ, Schwab IR. Bartonella henselae neuroretinitis in cat scratch disease. Diagnosis, management, and sequelae. Ophthalmology. Mar 1998;105(3):459-66. [Medline].
Mikkila H, Seppala I, Leirisalo-Repo M, Immonen I, Karma A. The etiology of uveitis: the role of infections with special reference to Lyme borreliosis. Acta Ophthalmol Scand. Dec 1997;75(6):716-9. [Medline].
Babu RB, Sudharshan S, Kumarasamy N, Therese L, Biswas J. Ocular tuberculosis in acquired immunodeficiency syndrome. Am J Ophthalmol. Sep 2006;142(3):413-8. [Medline].
Andreola C, Ribeiro MP, de Carli CR, Gouvea AL, Curi AL. Multifocal choroiditis in disseminated Cryptococcus neoformans infection. Am J Ophthalmol. Aug 2006;142(2):346-8. [Medline].
Ament CS, Young LH. Ocular manifestations of helminthic infections: onchocersiasis, cysticercosis, toxocariasis, and diffuse unilateral subacute neuroretinitis. Int Ophthalmol Clin. Spring 2006;46(2):1-10. [Medline].
Chalumeau M, Monnet D, Brezin AP, et al. Chorioretinal lesions as the unique feature of complete chronic granulomatous disease in an 8-year-old girl. Eur J Pediatr. Oct 2007;166(10):1069-70. [Medline].
Rigante D, Stabile A, Minnella A, et al. Post-inflammatory retinal dystrophy in CINCA syndrome. Rheumatol Int. May 8 2009;[Medline].
Weiss HA. Uveitis and Chrorioretinitis. In: Long S, ed. Principles and Practice of Pediatric Infectious Diseases. 3rd ed Edition. 2008:504-8.
Johannessen JK, Christiansen I, Schmidt DR, Petersen E, Hansen SH. Simultaneous determination of pyrimethamine, sulfadiazine and N-acetyl-sulfadiazine in plasma for monitoring infants in treatment of congenital toxoplasmosis. J Pharm Biomed Anal. Jan 4 2005;36(5):1093-8. [Medline].
Accorinti M. Ocular bartonellosis. Int J Med Sci. 2009;6(3):131-2. [Medline].
Patel SJ, Petrarca R, Shah SM, et al. Atypical Bartonella hensalae chorioretinitis in an immunocompromised patient. Ocul Immunol Inflamm. Jan-Feb 2008;16(1):45-9. [Medline].
Shah CP, McKey J, Spirn MJ, Maguire J. Ocular candidiasis: a review. Br J Ophthalmol. Apr 2008;92(4):466-8. [Medline].
Breit SM, Hariprasad SM, Mieler WF, Shah GK, Mills MD, Grand MG. Management of endogenous fungal endophthalmitis with voriconazole and caspofungin. Am J Ophthalmol. Jan 2005;139(1):135-40. [Medline].
Khan FA, Slain D, Khakoo RA. Candida endophthalmitis: focus on current and future antifungal treatment options. Pharmacotherapy. Dec 2007;27(12):1711-21. [Medline].
Osthoff M, Hilge R, Schulze-Dobold C, Bogner JR. Endogenous endophthalmitis with azole-resistant Candida albicans--Case report and review of the literature. Infection. Oct 2006;34(5):285-8. [Medline].
Prasad AG, Van Gelder RN. Presumed ocular histoplasmosis syndrome. Curr Opin Ophthalmol. Dec 2005;16(6):364-8. [Medline].
Wallon M, Kodjikian L, Binquet C, et al. Long-term ocular prognosis in 327 children with congenital toxoplasmosis. Pediatrics. Jun 2004;113(6):1567-72. [Medline].
Further Reading
Keywords
chorioretinitis, CR, retinochoroiditis, choroidoretinitis, congenital toxoplasmosis, CTP, congenital cytomegalovirus, CMV, congenital lymphocytic choriomeningitis virus, fungal infections, retinal vessels, infection, West Nile virus, Epstein-Barr virus, varicella-zoster virus, intrauterine growth retardation, microcephaly, microphthalmia, cataract, uveitis, hearing defect, osteomyelitis, hepatosplenomegaly, lymphadenopathy, dermal erythropoiesis, carditis, congenital heart disease, herpes simplex virus, ocular bartonellosis, infections, treatment, diagnosis
