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Syed Mahmood Shah, Elham Hatef Naimi, Peykan Turkcuoglu, Yasir J. Sepah, Matthew Shulman, Zubir S. Rentiya, Roomasa Channa, Diana V. Do, Yousuf M. Khalifa, Quan D. Nguyen; Importance of Proper Diagnosis and Management: Multifocal Choroiditis Mimicking Ocular Histoplasmosis Syndrome. Invest. Ophthalmol. Vis. Sci. 2011;52(14):2754.
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Differentiating between multifocal choroiditis (MFC) and ocular histoplasmosis syndrome (OHS) may be challenging, as both may present with chorioretinal (CR) lesions and lack of anterior chamber (AC)/vitreous inflammation. We evaluated a series of patients who were prevoiusly diagnosed with and managed as recurrent OHS, with subsequent progression and response to treatments consistent with MFC.
Nine patients (1 male; median age 38 years) were referred from 2008-09 with diagnosis of recurrent OHS lesions (n=6), likely OHS or PIC (n=2) and questionable OHS (n=1). Previous treatments for recurrent choroidal neovascularization (CNV) included bevacizumab (n=7), laser photocoagulation (n=2), photodynamic therapy (n=3), intravitreal triamcinolone (n=1); none was receiving any treatment for possible immune-mediated diseases. Upon referral, full serology panel was done to investigate autoimmune and infectious causes, and fluorescein angiography (FA) and optical coherence tomography (OCT) were performed to evaluate for active inflammation.
Examination showed multiple, small, punched-out peripheral CR scars and peripapillary atrophy with no AC/vitreous inflammation. Histoplasma antigen/antibody was negative in all patients. FA and OCT confirmed active inflammation (non-CNV) in 5 patients. Based on examination and negativity for other causes, a diagnosis of immune-mediated MFC was made in 7 patients, possible tuberculous choroiditis in 1 patient, and idiopathic CNV in 1 patient. Immunomodulatory therapy (IMT) was started in five patients, 1 patient received treatment for scleroderma; 2 patients were judged not to require IMT; 1 patient was managed for possible tuberculosis. Four of 5 patients with active inflammation treated with IMT had stable or improved vision with no recurrence of CNV or lesion activities.
Subjects with MFC may initially masquerade as OHS. Diagnosis of OHS should not be considered exclusively unless accompanied by positive serology and appropriate clinical characteristics. Serologic testing for Histoplasma capsulum, recently demonstrated with high sensitivity and specificity, should be employed to aid in the management of such patients. Absence of Histoplasma titer and presence of recurrent clinical characteristics of MFC may lead to consideration of IMT and other proper treatments for MFC.
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