Coexistent Ankylosing Spondylitis and Ocular Toxocariasis in a Pediatric Patient Manifesting As Bilateral Panuveitis

Abstract

The coexistence of ankylosing spondylitis and ocular toxocariasis in the literature is rare and limited to a few case reports. Typically, such cases present as acute nongranulomatous anterior uveitis with Toxocara IgG seropositivity. A patient manifesting with findings of both ankylosing spondylitis and toxocariasis bilaterally has not been reported previously in the literature. We present a case of coexistent juvenile spondyloarthritis and ocular toxocariasis in a 16-year-old male presenting with generalized pustules, back pain, peripheral polyarthritis, and bilateral panuveitis. Both eyes displayed abnormalities in the anterior segments, including corectopia, seclusio pupillae, and occlusio pupillae. Posterior segment examination of the right eye showed vitritis, disc edema, and a retinochoroidal granuloma surrounded by infiltrates and perivascular sheathing. A B-scan of the left eye revealed vitritis and the presence of a hyperechoic band from the disc to the retinal periphery. Toxocara IgG and HLA-B27 were positive, and lumbosacral magnetic resonance imaging confirmed sacroiliitis. Treatment involved subtenon injections of triamcinolone and subcutaneous Etanercept injections, resulting in stabilization of visual acuity. This case highlights the rare co-occurrence of two diseases with overlapping symptoms and uncertain pathogenetic contributions from each to cause the observed manifestations. It supports studies proposing a connection between rheumatic disease and parasitosis.

Keywords: ankylosing spondylitis; bilateral uveitis; granulomatous panuveitis; ocular toxocariasis; pediatric uveitis.

Figure 1. External exam findings of the right eye (A) with irregular, dilated, poorly reactive pupil, and posterior synechiae at 11, and 5-7 o’clock positions. Left eye (B) showing a small, nonreactive pupil, and occlusion membrane.

Figure 2. Ultrawide field fundus photograph of the right eye showing a hyperemic disc, retinal perivascular sheathing of both arteries and veins, confluent patches, retinal infiltrates, and exudates concentrated in the inferior retinal periphery, and a fibrovascular stalk from the disc to the noted area of intense inflammation. Indentation ophthalmoscopy revealed a peripheral granuloma surrounded by the confluence.

Figure 3. Axial scan of the left eye through closed eyelids showing a hyperechoic linear band with low to moderate amplitude echoes attaching to the optic disc and extending to the retrolental area and anterior retina.

Figure 4. Fluorescein angiogram of the right eye showing early hyperfluorescence of the disc with intense leakage during transit, pooling of dye in the fovea in a petalloid pattern, and a hyperfluorescent band from the disc extending inferiorly correlating with the fibrovascular structure seen on color photo.

Figure 5. Macular OCT scan of the right eye showing cystoid changes in the fovea extending nasally to the disc, consistent with uveitic cystoid macular edema and optic disc edema

Figure 6. Definite sacroiliitis is shown as bone marrow hyperintensities (orange arrows) around both sacroiliac joints in this pelvic MRI.