DIAGNOSTIC DILEMMAS IN A YOUNG PATIENT WITH SUSPECTED CHOROIDAL MELANOMA AND SARCOIDOSIS

The purpose of this case is to demonstrate the complexity in diagnosing and treating a young patient with granulomatous scleritis and secondary retinal detachment. The case is further complicated by suspected diagnosis of melanoma malignum choroideae and sarcoidosis which significantly impacts diagnostic and therapeutic decisions.

melanoma malignum choroideae, sarcoidosis, scleritis, secondary retinal detachment, complications

This case follows 26 year old female with progressive visual acuity loss in the left eye (VOS: HM), the right eye maintained normal visual acuity(VOD: 20/20 UVA). Her medical history includes left axillary lymphadenectomy and a prior COVID-19 infection (COVID-19 SARS-CoV-2 IgG (S1+N): 3.290). Initial ophthalmologic examination showed a prominent tumor mass in the inferior temporal quadrant. Anterior chamber was of medium depth with + cells present, iris showed posterior synechiae, and the pupil was distorted, slightly dilated, and nonreactive. Fundus of the left eye showed total retinal detachment and sonography revealed a medium-reflective subretinal mass indicative of an inflammatory etiology. Initially suspected diagnose was malignant choroidal melanoma. Diagnosis was later sent for a second opinion to the Center for Malignant Ocular Diseases abroad, where a hypothesis of melanoma malignum choroidae was proposed. A recommendation for surgical treatment was made, contingent upon the exclusion of sarcoidosis. We conducted a series of analyses, with the following results: biochemical analysis of chitotriosidase 30.4 ng/mL and Toxoplasmosis IgG (TOXO IgG) +7.9 IU/mL. Based on these results, sarcoidosis was considered as a possible diagnosis. After several months a choroidal granuloma with signs of posterior uveitis appeared in the right eye. Corticosteroids (methylprednisolone) and immunosuppressants (Methotrexate) were used in combination, with doses gradually reduced.

After one month of treatment the right eye showed resolution of the choroidal granuloma preserving stable visual acuity. The left eye had retinal detachment and persistent lesion though it was reduced in severity.

This case illustrates some of the challenges that are posed in diagnosing and management of the condition. The patient's clinical presentation necessitated international collaboration for accurate diagnosis. For optimizing the treatment strategies and impruving our outcomes we need  further examinations and continuous monitoring.