Occam’s Razor Versus Hickam’s Dictum: Bilateral Panuveitis in a Patient with Presumed Ocular Toxocariasis And Coexistent Juvenile Spondyloarthritis



We report a case of juvenile ankylosing spondylitis coexistent with presumed ocular toxocariasis manifesting as bilateral panuveitis and discuss the pathogenetic contributions of each disease entity.


We highlight the case of a 16 year- old male with juvenile spondyloarthritis and presumed ocular toxocariasis affecting both eyes. He presented with generalized pustules, back pain, peripheral polyarthritis, and bilateral panuveitis. Both eyes revealed sequelae of anterior uveitis: anterior and posterior synechiae, corectopia, and occlusio pupillae on the left eye. Right eye fundus photography showed vitritis, disc hyperemia, and granuloma on indentation indirect ophthalmoscopy surrounded by infiltrates and perivascular sheathing. A fibrovascular stalk was seen extending from the granuloma to the disc.


B Scan of the left eye showed vitritis and hyperechoic band from the disc to the retinal periphery without aftermovement. Fluorescein angiogram and macular optical coherence tomography of the right eye confirmed cystoid macular edema and papillitis. Lumbosacral magnetic resonance imaging revealed sacroiliitis, fulfilling ILAR and ASAS criteria. Work-up was done to exclude other possible infectious and inflammatory entities. Treatment included steroids and anti-TNF inhibitors with visual acuity stabilization and symptom resolution.


This case illustrates a rare co-occurrence of two diseases with significant overlap and unclear pathogenetic contributions from each to cause the observed signs and sequelae. This renders support to studies suggesting the link between rheumatic disease and parasitosis. Invoking Hickam’s dictum over diagnostic parsimony by Occam’s razor may sometimes be a more sensible means of clinching a diagnosis.

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