71

Clinical Brief
Globe Calcification in Congenital Toxoplasmosis
N.R.S. Surendrababu, K.A. Kuruvilla, A.K. Jana and Rekha Cherian
Department of Radiodiagnosis, Department of Neonatology
1
Christian Medical College Hospital, Vellore Tamil
Nadu, I ndia.
ABSTRACT
Various patterns of distribution of intracerebral calcification have been described in congenital toxoplasmosis. We report a case
of congenital toxoplasmosis with a rare finding of calcification in the globe detected by CT scan that has not been described
earlier. [Indian J Pediatr 2006; 73 (6) : 527-528] E-mail : nrssbabu@yahoo.com
Key words : Globe calcification; Congenital toxoplasmosis; Retinochoroiditis
Congenitaltoxoplasmosisusuallypresentswithatriadof
chorioretinitis,cerebralcalcificationandconvulsions.
Retinochoroiditisispathognomicofoculartoxoplasmosis,
accountingfor95%ofcases.
1
Thesepatientsmayalso
presentwithretinalvasculitis,vitritis,anterioruveitisand
scleritis.
2
Later,theymaydevelopretinochoroidalscars.
3
Wereportacaseofcongenitaltoxoplasmosiswitharare
findingofcalcificationintheglobedetectedbyCTscan.
CASE REPORT
A single live preterm boy baby born at 35 weeks
gestationwasadmittedtothenurseryforrespiratory
distress. He was born to a primigravida bynormal
vaginaldeliverywithApgarscoresof9and10at1and5
minutes,respectively.Hisbirthweightwas2780g,head
circumference32.5cmandlength47cm.Onexamination,
the notable findings were tachypnoea and dry,
erythematousskin.Theliverwassoftandpalpable5cm
belowtherightcostalmargin;asoftspleenwasalso
palpable4cmbelowtheleftcostalmargin.Complete
bloodcountswerenormalexceptforthrombocytopenia
(platelets77,000/cumm).Serumelectrolytes,calcium,
phosphorusandbloodsugarlevelswereinthenormal
range.Thechestradiographshowedpneumonitis.Onthe
secondday,thebabywasfoundtobejitteryandhadtwo
episodesofconvulsions.Thesefeaturesofapretermbaby
raisedthesuspicionofcongenitalintrauterineinfection
andadetailedwork-upwasperformed.
Radiographoftheskullanteroposteriorview(Fig.1),
Correspondence and Reprint requests :Dr.N.R.S.Surendrababu,
Lecturer,DepartmentofRadiodiagnosis,ChristianMedicalCollege
Hospital,Vellore632004,TamilNadu,India.Fax:91-416-2232103.
showedmultiplecorticalcalcificationsandacalcificfocus
intheleftorbit.AxialCTsectionsofthebrainshowed
multiplefociofcalcificationbilaterallyincerebralcortex
cerebellumandinthebasalganglia.Inaddition,nodular
calcificationattheposteriorpoleoftheglobeintheleft
orbitwaspresent(Fig.2).Ophthalmologicalevaluation
showed anterior uveitis, bilateral cataract and
Fig. 1. Anteroposteriorradiographofskullshowingbilateral
cerebralcorticalcalcificationsandacalcificfocusinleftorbit.
Indian Journal of Pediatrics, Volume 73June, 2006 527
72
Surendrababu et al
Fig. 2. ComputedTomography(CT)scanofbrainandorbitsatthe
levelofthefourthventricleshowingcalcificationintheleft
cerebellarhemisphere,temporallobes,andposteriorpoleof
theglobeoftheleftorbit.
hemorrhagesintheretina.SerologyforToxoplasma-
specificIgMantibodieswaspositivebothinthemother
and infant, confirming the diagnosis of congenital
toxoplasmosis.SerologyforCMV,rubellaandherpes
simplexviruses1and2wasnegative.
Therapyforcongenitaltoxoplasmosiswascommenced
withsulfadoxime,pyrimethamineandfolinicacid.In
addition, local and systemic steroid therapy was
administeredforophthalmicinvolvement.
DISCUSSION
Cerebralcalcificationisdescribedin65%ofpatientsof
congenitaltoxoplasmosis.
1
Usuallythecalcificfociare
distributed diffusely in the cerebral parenchyma,
predominantly in the cortex, basal ganglia or
periventricular region. In a review of the English
languagepress,nodularcalcificationattheposteriorpole
oftheglobethatwaspresentinthiscasehasnotbeen
reported.
Thecoatsoftheeyecannotbeidentifiedseparatelyon
CTscan:calcificationinthewalloftheposteriorhalfof
theglobecouldbescleral,choroidalorretinalinlocation.
Intraretinal calcification classically occurs in
retinoblastoma.Itmayalsobeseeninretinocytoma,
tuberous sclerosis and epiretinal membranes.
4
Sclerochoroidalcalcificationcouldbedystrophicor
metastaticinnature.
5
Dystrophiccalcificationiscausedby
secondarydepositionofcalciuminabnormaltissues
despitenormalserumlevelsofcalciumandphosphate,
whereasmetastaticcalcificationresultsfromdepositionof
calciuminnormaltissuescausedbyabnormalcalcium-
phosphorusmetabolism.
5
Metastaticcalcificationoccurs
in primary and secondary hyperparathyroidism,
pseudohypoparathyroidism,sarcoidosisorinrenal
tubularalkalosissyndromessuchasBartterandGitelman
syndromes.
6-8
Rarely,sclerochoroidalcalcificationis
idiopathicandseeninelderlywhitemales.
9
Chorioretinitisistheprimaryocularpathologyof
congenitaltoxoplasmosisoccurringin95%ofcases.Eye
involvementisbilateralin88%ofpatients
1
;however,in
thiscase,calcificationoftheglobewasunilateral.The
hallmark of the disease is focal necrotizing
retinochoroiditisthatleadstoaretinochoroidalatrophic
scar.
3
Clinicallyestablishedretinochoroidalscarshave
beenidentifiedatbirthinsomeinfants.
10
Thediagnosis
maybemadebyophthalmicexamination,fluorescein
angiography,orocularultrasonographyandconfirmed
on computed tomography.
6,8,9
In congenital
toxoplasmosis,thecalcificationseenintheglobecanbe
considered to be chorioretinal in location with
involvementofsclera.Thepresumedmechanismwould
bedystrophiccalcificationatthesiteofchorioretinaland
scleralinflammation.
Among children being evaluated for suspected
congenitaltoxoplasmosiswithneurologicalinvolvement,
radiologists,pediatriciansandophthalmologistsshould
befamiliarwiththisrarefindingofglobecalcification.
REFERENCES
1. SafadiMA,BerezinEN,FarhatCK,CarvalhoES.Clinical
presentationandfollowupofchildrenwithcongenital
toxoplasmosisinBrazil.Braz J Infect Dis 2003;7:325-331.
2. Nussenblatt RB, Whitcup SM, Palestine AG. Ocular
toxoplasmosis.InUveitis:FundamentalsandtheClinical
Practice.2ndedn.StLouis;Mosby,1996;211-288.
3. Bosch-Driessen LE, Berendschot TT, Ongkosuwito JV,
RothovaA.Oculartoxoplasmosis:clinicalfeaturesand
prognosisof154patients.Ophthalmology2002;109:869-878.
4. MillerDM,BenzMS,MurrayTG,DubovySR.Intraretinal
calcificationandosseousmetaplasiainCoatsDisease.Arch
Ophthalmol2004;122:1710-1712.
5. Boutboul S, Bourcier T, Heligon JP et al. Familial
pseudotumoralsclerochoroidalcalcificationassociatedwith
chondrocalcinosis.Br J Ophthalmol 2004;88:1094-1095.
6. SuzukiJI,TakedaM,SekineN et al.Bilateralmetastatic
sclerochoroidal calcification in a patient with
hyperparathyroidism.Ophthalmologica1992;205:10-14.
7. Bourcier T, Blain P, Massin P, Grunfeld JP, Gaudric A.
Sclerochoroidal calcification associated with Gitelman
syndrome.Am J Ophthalmol 1999;128:767-768.
8. VezzoliG,SoldatiL,JansenAet al.Choroidalcalcificationsin
patientswithGitelmanssyndrome.Am J Kidney Dis2000;6:
855.
9. SchonherrU,GraupnerM.Sclerochoroidalcalcification-arare
diseasepatternreportontwopatients,differentialdiagnosis
andreviewoftheliterature.KlinMonatsblAugenheilkd2003;
220:39-43.
10. MetsMB,HolfelsE,BoyerKMet al.Eyemanifestationsof
congenitaltoxoplasmosis.Am J Ophthalmol 1996;122:309-324.
Indian Journal of Pediatrics, Volume 73June, 2006 528