获得性眼弓形虫视网膜脉络膜炎误诊一例

doi:10.3877/cma.j.issn.2095-2007.2022.04.007

患者女性，55岁。因左眼视物模糊1个月于2021年6月28日就诊于山西省临汾市尧都区眼科医院青光眼二组。既往有足癣10余年，控制良好，半年前有犬划伤史，有养猫史，无高血压、糖尿病及家族性遗传病史。右眼视力0.4，左眼0.08，右眼眼压9.5 mmHg(1 mmHg＝0.133 kPa)，左眼8 mmHg。右眼结膜淡红色，角膜透明，前房清且深浅正常，瞳孔约3 mm，光反射灵敏，晶状体轻度混浊，玻璃体清，豹纹状眼底改变，视盘边界清晰，杯盘比0.3，黄斑中心凹反光可见，视网膜血管走行正常；左眼结膜淡红色，角膜透明，下方内皮可见尘状角膜后沉着物，前房深浅正常，房水闪辉(++)，瞳孔约3 mm，光反射灵敏，晶状体混浊，玻璃体细胞(+++)，玻璃体混浊(++++)，上方可见条状混浊，豹纹状眼底改变，视盘边界清晰，杯盘比0.3，黄斑区可见黄白色病灶。见图1A。视网膜静脉扩张迂曲，动静脉血管可见血管白鞘，Kyrieleis斑，鼻侧视网膜可见约3个视盘直径大小的黄白色病灶，边界不清，视网膜前和其下方周边可见黄白色串珠样混浊。见图1B。使用Spectralis HRA型荧光素眼底血管造影(德国海德堡公司生产)检查，可见玻璃体混浊遮挡，病灶边缘高荧光渗漏，其内低荧光夹杂高荧光。见图2。使用MD－2400S B型超声(天津迈达医学科技有限公司生产)检查，可见左眼玻璃体混浊伴后脱离，视网膜水肿待排除。见图3。使用RTvue100型光学相干断层扫描(optical coherence tomography，OCT)仪(美国Optovue公司生产)检查，可见左眼黄斑中心凹厚182 μm，视网膜表面斑片状中强反射。见图4A。病灶区视网膜萎缩，周边视网膜表面点状中强反射，视网膜全层萎缩。见图4B。血常规、肝肾功能及感染四项等检查结果正常。初步诊断为左眼疑似内源性真菌性眼内炎。收入院后左眼行玻璃体穿刺，抽取液体行眼内液病原学和免疫学检测；同时左眼经验性球内注射氟康唑注射液0.2 mg(辰欣药业股份有限公司生产)，全身行抗真菌治疗，氟康唑注射液0.2 g，静脉滴注1次/d，待眼内液检查结果回报后进一步调整治疗。5 d后眼内液宏基因组检测结果显示，刚地弓形虫(+)。血清学检测结果显示，弓形虫抗体免疫球蛋白(immunoglobulin，Ig)G(+)，IgM(－)；巨细胞病毒IgG(+)，IgM(－)；风疹病毒IgG(+)，IgM(－)。修正诊断为左眼获得性眼弓形体性视网膜脉络膜炎。给予复方磺胺甲噁唑片(山东新华制药股份有限公司生产)2片，口服，2次/d；盐酸克林霉素胶囊(山东方明药业集团股份有限公司生产)0.15 g，口服，2次/d。左眼玻璃体注射克林霉素磷酸酯注射液0.1 ml(辰欣药业股份有限公司生产)。3 d后患者症状略缓解，玻璃体混浊减轻，治疗1周后加用醋酸泼尼松片(上海上药信谊药厂有限公司生产)60 mg，口服，1次/d，晨起顿服，序贯减量。治疗4周后左眼矫正视力提高至0.5，结膜无充血，角膜透明，角膜后沉着物消失，前房深浅正常，房水闪辉(－)，瞳孔约3 mm，光反射灵敏，晶状体轻度混浊，玻璃体细胞(++)，玻璃体混浊(++)，较前减轻，仍有豹纹状眼底改变，视盘边界清晰，杯盘比0.3，视网膜血管白鞘及Kyrieleis斑块减少，黄斑区仅隐约可见淡黄色病灶。见图5A。鼻侧视网膜可见黄白色病灶减小，分为两个大小不一的黄白色病灶伴色素变动，边界清晰。见图5B。OCT检查结果显示左眼黄斑中心凹视网膜表面斑片状中强反射病灶较前缩小。见图5C。病灶区视网膜萎缩，结构紊乱，病灶周边视网膜表面点状中强反射，外层视网膜萎缩。见图5D。1个月后病情好转，继续抗弓形虫全身治疗。

图5 患者术后1个月左眼的眼底影像学检查成像　图5A和图5B分别示眼底后极部和眼底鼻侧的彩色照相，可见玻璃体混浊较术前减轻，视网膜血管白鞘及Kyrieleis斑块减少，黄斑区可见黄白色病灶较前变小，鼻侧视网膜可见黄白色病灶减小，分为两个大小不一的黄白色病灶伴色素变动，边界清晰；图5C和图5D分别示左眼黄斑区和病灶区的光学相干断层扫描成像，可见黄斑中心凹视网膜表面斑片状中强反射病灶较前缩小

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One misdiagnosed case of acquired Toxoplasma gondii retinochoroiditis

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One misdiagnosed case of acquired Toxoplasma gondii retinochoroiditis