The Editor,
Sir,
A 25-year old female patient who was under treatment for ankylosing spondylitis (AS) for two years presented to our clinic with blurred vision that had started in the right eye two weeks previously. The visual acuity (VA) in the right eye was 2/10, while it was 10/10 in the left eye. The biomicroscopic examination revealed +2 cells in the anterior chamber and the vitreous, and chorioretinitis superiorly to the optic disc in the right eye (Fig. 1).
Fig. 1. Colour fundus photograph showing scar formation and active chorioretinitis in optic disc superiorly at first visit.
The left eye was observed to be normal. The patient's history revealed that she was under treatment with etanercept for the last three months. Her blood count and biochemistry results were normal. ToxoIgG was positive while the ToxoIgM was negative.
Among the other serological markers, syphilis, brucella and tuberculosis were negative. Based on these findings, the patient was diagnosed with ocular toxoplasmosis and treatment with the biological agent was stopped. The patient was started on a regimen of clindamycin, steroids and trimethoprim/sulfamethoxazole for six weeks. Following the treatment, the VA of the patient returned to 10/10 in both eyes with scarring superiorly to the optic disk (Fig. 2).
Fig. 2. Colour fundus photograph showing scar formation in right eye after treatment at last visit.
Ankylosing spondylitis is a chronic, progressive and inflammatory rheumatic disease characterized by axial and peripheral joint involvement, which may cause severe disability (1). Currently, if the disease activity continues in spite of the conventional treatments, anti-tumour necrosis factor-alpha (TNF-α) agents may be used. However, patients should be kept under close monitoring for the side effects of the treatment with biological agents (2). Biological agents may be associated with a higher incidence of granulomatous infections including tuberculosis (3). Still, there is only a limited number of reports regarding patients observed to develop toxoplasma infections during treatment with anti-TNF-α agents and these include rheumatoid arthritis patients with chorioretinitis treated with either etanercept or infliximab (4).
In conclusion, we reported a case of toxoplasmic chorioretinitis in a patient treated with anti-TNF-α agents. The possibility of severe toxoplasma infection during the anti-TNF-α therapy should be kept under consideration due to its serious ocular consequences, which may lead to major sequelae. We are of the opinion that patients should be advised to avoid exposure to infectious agents including toxoplasma before and during treatment with anti-TNF-α.
REFERENCES
- 1.Linssen A, Meenken C. Outcomes of HLA-B27 positive and HLAB27 negative acute anterior uveitis. Am J Ophthalmol. 1995;120:351–361. doi: 10.1016/s0002-9394(14)72165-8. [DOI] [PubMed] [Google Scholar]
- 2.Landewé R, Rump B, van der Heijde D, van der Linden S. Which patients with ankylosing spondylitis should be treated with tumour necrosis factor inhibiting therapy? A survey among Dutch rheumatologists. Ann Rheum Dis. 2004;63:530–534. doi: 10.1136/ard.2003.011130. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Keane J, Gershon S, Wise RP, Mirabile-Levens E, Kasznica J, Schwieterman WD, et al. Tuberculosis associated with infliximab, a tumour necrosis factor alpha neutralizing agent. N Engl J Med. 2001;345:1098–1104. doi: 10.1056/NEJMoa011110. [DOI] [PubMed] [Google Scholar]
- 4.Lassoued S, Zabraniecki L, Marin F, Billey T. Toxoplasmic chorioretinitis and antitumor necrosis factor treatment in rheumatoid arthritis. Semin Arthritis Rheum. 2007;36:262–263. doi: 10.1016/j.semarthrit.2006.08.004. [DOI] [PubMed] [Google Scholar]