Toxoplasma gondii retinochoroiditis associated with Epstein-Barr virus-induced retinal necrosis in an immunocompetent patient

PURPOSE: To describe a rare case of concomitant Toxoplasma gondii (Tg) retinochoroiditis and Epstein-Barr virus (EBV) retinal necrosis in an immunocompetent patient, successfully treated with a combined intravitreal and systemic therapeutic approach. METHODS: A 52-year-old immunocompetent woman with recurrent bilateral Tg retinochoroiditis presented with reactivation in the left eye unresponsive to standard antiparasitic therapy. Comprehensive ophthalmological examination, including diagnostic pars plana vitrectomy with vitreous biopsy and polymerase chain reaction (PCR) analysis, was performed. RESULTS: PCR analysis of the vitreous sample confirmed the presence of both Tg and EBV. Intravitreal methotrexate (MTX) was initiated and administered over an 8-week period in combination with ongoing intravitreal clindamycin and systemic antiparasitic therapy, together with systemic acyclovir (800 mg three times daily). The patient demonstrated progressive clinical improvement, with stabilization of visual acuity and retinal morphology on optical coherence tomography (OCT). Serial vitreous PCR monitoring revealed a gradual decline in Tg and EBV loads until both pathogens became undetectable. No recurrence occurred during follow-up. CONCLUSION: This report describes a rare case of Tg-EBV coinfection-related retinochoroiditis in an immunocompetent patient. The favorable outcome observed after initiation of intravitreal MTX, in combination with systemic acyclovir, suggests that MTX may have contributed to disease control through immunomodulatory suppression of B-cell proliferation and possible antiviral effects. This case underscores the importance of considering coinfection in atypical or treatment-refractory retinochoroiditis, even in immunocompetent hosts.