A diagnostic dilemma: infectious versus noninfectious multifocal choroiditis with panuveitis

A 68-year-old female presented with new onset of floaters in both eyes and diagnosed with bilateral panuveitis. Her visual acuity was 20/200 in both eyes. Slit-lamp examination showed 1+ anterior chamber cells in both eyes. Ophthalmoscopic examination of both eyes showed vitreous cells, optic disc edema, small amounts of subretinal hemorrhage, and punctate choroidal lesions throughout the fundus. Laboratory work-up revealed a positive QuantiFERON-TB Gold result, and the patient was started on antituberculosis medications. However, given the patient’s intolerance to antituberculosis medications and progressive worsening of vision, she underwent a chorioretinal biopsy to assist with determining a definitive diagnosis. Biopsy results showed noncaseating granulomas and were negative for an infectious etiology. The patient was diagnosed with ocular sarcoidosis and started on immunomodulatory therapy for sarcoid-related multifocal choroiditis.Multifocal chorioretinal lesions of unknown etiology can present as a diagnostic and therapeutic dilemma. Laboratory work-up is useful in determining an etiology; however, more invasive procedures, such as chorioretinal biopsy, may be necessary to guide treatment.A 68-year-old nurse presented with new onset of floaters in both eyes in August 2009. She noted her symptoms to be painless without eye redness or discharge. She stated that her symptoms progressively worsened with decreasing visual acuity. She was initially seen by an ophthalmologist 2 months after her symptoms started and was diagnosed with bilateral panuveitis. She denied any trauma or injury to the eye, or having any previous ocular history. Her past medical history was significant for insulin-dependent type 2 diabetes mellitus, hypertension, and hypercholesterolemia. She has a history of being purified protein derivative (PPD) positive with a negative chest X-ray, for which she had never received treatment.Her visual acuity was initially 20/200 in the right eye and 20/2