 All right good morning everyone we'll go and get started. Today we have three separate talks delivered by our chief residents and our Cognia fellow. We're gonna start with Dr. Chris Conraddy. He's our chief resident as you know and I'm really proud of him. He's matched into the UDitis Fellowship right here at the Moran so he'll be staying with us next year. Today he's gonna present on retinitis and the immunocompromised. Anyone's guess? Sounds interesting. Okay so I promise this will be a fairly short talk. Okay so I was already kind of introduced this but and I'll kind of walk through it. It's a single case presentation that we actually have under review right now at a journal that I think you guys will find interesting. One just because of the kind of surprise that caught us off guard and the other being just kind of some diagnostic tools that I as a scientist I don't know why we don't use them more in the clinical realm but I think they're starting to catch a little bit of steam in the clinical sector and I think that will increase since I think it's good for you guys to at least be aware of as we go forward. So I have no financial disclosures. I'm a poor resident so it's nothing to declare and so basically to start the case this is a 69-year-old gentleman that was an immigrant from Ecuador. His only past medical history is that he had basically undergone multiple rounds of chemotherapy and stem cell transplants for multiple myeloma and when he actually presented the ophthalmology clinic he was currently receiving kind of some salvage therapy of chemotherapy and there those are the agents there so he was immunosuppressed at least from that standpoint and he initially presented ophthalmology clinic with blurry vision and pain around the left eye and that had been going on for a couple of weeks prior to his presentation in the clinic. The right eye on examination so that was the completely asymptomatic eye was unremarkable at least from the external examination so I'll focus on the left eye. Left eye had hand motion vision when he was seen. Anterior segment was notable for KP, one plus cell and flare and then one plus cell of the anterior vitreous face. On dilated eye exam so in the right eye you can see that he actually had a little sorry he had a little hemorrhage here we felt that that was related to his ongoing thrombocytopenia so it was otherwise unremarkable. However in his left eye the symptomatic eye he had diffuse retinal whitening he had an inferior retinal detachment scattered retinal hemorrhages and then you can't really see it in this picture just due to all the different focal planes from this retinal detachment but he also had optic nerve edema so pretty significant involvement of the poster segment of the left eye. Mac OCT was performed and you can just see that this kind of reiterates the fluid is all the way to the macula. There's some retinal thickening here and then you can't see it here but there was also some caroidal thickening as well. So then this picture at least initially looked like any presumably a necrotizing viral retinitis and so he was actually started on Valtrex and given an intravitural FOSC carnet. After a few days and then of course with every uveitis work up they get the vampires after them and they get blood drawn and so he actually went underwent an AC tap at that time all the herpetic organisms were negative and then he also underwent some systemic labs that were also unremarkable. So at this point we're kind of scratching our head we have this presumably viral necrotizing retinitis negative lab work. However we gave him initial treatment then we started him on actual oral steroid taper a couple days later. The inflammation actually improved however his vision continued to decline so when he returned he had no light perception vision in that eye. Due to that concern and maybe concern of this going to the other eye or this being something much more significant we ended up doing where Dr. Shakur did it. Pars plant attracted me with vitreous biopsy and sent that for flow cytometry and panorganism PCR and we'll talk a little bit about that here in a second and to everyone's kind of surprised and this is kind of why it's interesting and we'll talk more about as we go. We were kind of perplexed the only organism on this panorganism PCR was trapanosoma cruciate. So that's the kind of organism that causes Chagas disease we'll talk about that a little bit more. So then we decided to kind of in the the workup process with intraocular findings presumably of trapanosoma cruciate. He underwent serum PCR and IgG analysis both of which were positive. So we sent him to the infectious disease department. They ended up talking to the CDC or actually in the process of getting him treatment for basically reactivated Chagas disease. However around that time he developed a small bowel obstruction and actually went home on comfort care instead of pursuing treatment that has quite a bit of side effects actually from a treatment standpoint. So why is this interesting? Well first of all so Chagas disease we don't see it a lot. Maybe it's under reported actually in the United States because of some immigration issues we don't necessarily have it high on our differential. However there's about six million people in the United States that are infected with Chagas disease. It's passed through a vector-borne transmission resulting in basically lifelong infection without adequate treatment. So basically once you've been infected if you haven't been treated which there aren't great treatment options then you're basically indefinitely infected. It has a tropism as we've all learned in medical school for basically myocardial tissue and about 30% of cases and then GI and neuronal tissue and about 10 to 20% of cases. That's where most of the kind of major issues arise. What we know at least from Chagas and the eye so we don't know actually a lot. What we do know is that you can infect goats with basically an organism so a sister organism of Chagas disease and they actually will get choreoretinitis. Then people have actually suggested in mouse models that the cornea could actually serve as a reservoir for Chagas disease and it could reactivate from actually the cornea so that something that needs to be addressed from a corneal transplant issue. I don't know that's a big question. Then we do know that in at least in South America specifically in Argentina where most of these studies have come out of that patients with long-standing Chagas disease will get RPE changes seems to be visually insignificant so it doesn't seem to have any sort of visual impact. Then also out of Argentina these cases were in congenital Chagas but a couple of actually very young infants were referred for presumably ROP and actually found to have disseminated Chagas disease that developed posterior uveitis rather than ROP and so they ended up being treated with basically systemic anti Chagas therapy and the posterior uveitis resolved. So interesting at least from the diagnosis standpoint right but the thing that may be of more kind of pertinence to all of us rather than chasing zebras is kind of the use of pain orgasm PCR and this is kind of what I alluded to initially of something that I think will be well it's already becoming more standard of care than it was 10 years ago. So PCR has been around for a long time. What we know at least from organism or at least organism isolation in ocular diseases so in the EVS so the vitrectomy study in the mid 90s only 30% of those cultures were that's actually positive so 30% the cultures were positive larger studies since that time have and this is using old techniques so basically plating the or the specimen on plates and then trying to grow them in labs 50% of ocular cultures seem to grow something out of so at least 50% of the samples we send are growing no organisms and therefore we can't target therapy to a specific organism. What we also know is that PCR has outperformed culture-based techniques and HSV isolation and that there's quite a bit of emerging literature now that PCR is actually outperforming old techniques so culture techniques to identify organisms and specimens so previously negative specimens at least from a microbiology standpoint are now identifying organisms through PCR analysis and that's just a lot of that's just related to sensitivity it's pretty hard to grow some of these organisms especially pretty fast-stidious organisms in the lab setting let alone from organisms isolated from specific sites in the human body and so with that said I'm not gonna talk much more because we've got several talks but a lot of people have been instrumental in this the big thing I think to kind of go forward with this so there most of the PCR analysis is done at the University of Washington there's actually an infectious disease doctor here too that's interested in maybe doing some deep sequencing of things as well and so that that's maybe something that becomes more central to University of Utah as well so with that if there are any questions I'm happy to take those at this point otherwise we'll move on to our next talk