Hi,
Welcome back to icliniq.com.
You did not mention that you were taking Sulfamethoxazole Trimethoprim in the first query and I thought you were on one drug only. The prescribed regimen is adequtate for the treatment of toxoplasmosis, which nonetheless has not been confirmed in any of the lab tests that I went through. The alternative treatments for toxoplasmosis would be Pyrimethamine 200 mg orally on day one followed by 50 mg daily for four weeks with Sulfadiazine 2 g orally as a loading dose followed by 1 g orally 4 times daily for 4 weeks (along with Folinic acid 15 mg orally twice a week and increased water intake with Bicarbonate sodium). Azythromycin 500 mg once daily for four weeks instead of Clindamycin along with the same Trimethoprim Sulfamethoxazole 160/800 twice daily for four weeks. Considering that you have vision threatning lesions in the form of macular edema I would have went with intravitreal injection of Ranibizumab (anti vegf) or even Dexamethasone once I had you taking the antibiotics or start you on Prednisone 1.5 mg/kg/day orally and then taper it within four weeks or as your doctor preferred a periocular injection of 40 mg Triamcinolone is also indicated. When it came to detection of viruses, toxoplasmosis was negative but infectious mononucleosis IgG was positive on 25.04.2019. Herpes Zoster IgG was high in two or more lab tests along with adenovirus IgG . All of this would not signify anything if in the past you have been vaccinated for these viruses and this is why the IgG is elevated so I would also like to know your history of vaccinations. When it comes to infectious mononucleosis however, please include in the next update whether you have or are experiencing the following: episodes of fever, lymphadenopathy (swelling of the lymph nodes), pharingitis? Or currently experiencing malaise and fatigue, myalgia, headaches? Have you developed any rash after taking the antibiotics? I would like you to submit a lab test for epstein barr and liver function and undergo abdomen ultrasound with concentration on spleen and an orbit ultrasound to exclude a periorbital edema because ophthalmic complications might include conjunctivitis, episcleritis, and uveitis. Clinically, the most commonly used intravitreal steroid is Triamcinolone Acetonide because of its durability and clinical efficacy associated with the stability of its depot formulation. However, Triamcinolone acetonide has been reported to have direct cytotoxicity on retinal cells in culture, might lead to an increase in intraoular pressure and therefore is injected in the periocular area to decrease that cytotoxic effect, whereas recent clinical researches show that the injection of 0.1 ml of Dexamethasone into the eye gives way better results because it is less toxic and provides the primary effect to the retina without causing systemic side effects and it delivers a supreme concentration of the drug and its efficacy for inflammation than when taking it orally. As I mentioned earlier, it is very uncommon to use Dexamethasone intravitreally, although I support it more than having the patient take it orally, because there are injectable eye implants that slowly and safely release the steroid inside the eye. Triamcinolone however has been commonly used for macular edemas and to reduce ongoing inflammations inside the eye but also has its side effects. The purpose of injecting a steroid into the eye is reduce the inflammation and reduce the macular edema but for that purpose we have a way safer drug which is Ranibizumab (Lucentis) or Bevacizumab (Avastin) which acts quickly and has many additional benefits to the retina. I would advise your doctor to proceed with this injection if the macular edema has reocurred.