Nodulose reumatóide epibulbar bilateral: relato de caso

A 64-year-old woman with a diagnosis of rheumatoid arthritis developed painless bilateral episcleral rheumatoid nodules without any flare-up of her associated disease. Biopsy of the lesions disclosed a lymphocytic and plasmacytic infiltration within the conjunctiva, overlying palisading granulomas with multinucleated giant cells, and central necrobiotic degeneration of the collagen of the episclera and superficial sclera. The rheumatologic designation for the development of groups of nodules in inactive rheumatoid arthritis is rheumatoid nodulosis.

[Thoracic pain, sudden sedimentation rate decline, microhematuria and a red ear--what the clinician should also consider!]

Eine 71-jährige Patientin wurde vom Hausarzt zur Abklärung von Dyspnoe und rechts-thorakalen Schmerzen zugewiesen. Sie wurde bis zur Einweisung während zwei Wochen wegen Verdachts auf Pneumonie mit drei verschiedenen Antibiotika erfolglos behandelt. Die Patientin hatte bei Eintritt erhöhte Entzündungsparameter (CRP 77 mg/l, BSG 90 mm/h) und beidseitige Pleuraergüsse im Röntgenbild. Am Folgetag klagte sie über Schmerzen im Bereich des linken Ohres, das gerötet, überwärmt und geschwollen war. Da das Ohrläppchen ausgespart war, wurde die Diagnose einer Perichondritis gestellt. Zusätzlich entwickelte die Patientin eine Episkleritis des rechten Auges, die BSG stieg auf über 100 mm/h an, das Kreatinin betrug 96 µmol/l und die Urinuntersuchung zeigte eine glomeruläre Mikrohämaturie und eine Proteinurie. Die c-ANCA-Serologie war mit einem Titer von 1:2560 deutlich positiv. Die Nierenbiopsie zeigte eine extrakapillär proliferative, pauciimmune Glomerulonephritis, vereinbar mit der Diagnose eines Morbus Wegeners. Unter kombinierter Immunosuppression mit Prednison (50 mg/Tag) und Endoxan (100 mg/Tag) war der Verlauf durch das Verschwinden der Perichondritis, Pleuritis, Episkleritis und durch eine Normalisierung der Nierenfunktion gekennzeichnet. Eine Perichondritis des Ohres ist ein seltenes, jedoch wichtiges Präsentationszeichen eines Morbus Wegeners.

Masquerade scleritis

PURPOSE

To report two cases in which malignancy masqueraded as scleritis, delaying the diagnosis.

METHODS

Two patients initially diagnosed and treated for unilateral scleritis were referred for management of persistent inflammation. Additional evaluation uncovered underlying malignant processes.

RESULTS

The first patient presented with scleritis initially responsive to systemic corticosteroids, with relapse one month later. Upon referral, peripheral fundus examination revealed elevated lesions. Additional studies confirmed the diagnosis of choroidal melanoma. The patient was treated with proton-beam irradiation. The second patient developed necrotizing scleritis unresponsive to systemic steroids, methotrexate, and cyclophosphamide. A scleral biopsy disclosed an undifferentiated high-grade carcinoma, likely metastatic. Exenteration was performed.

CONCLUSIONS

Scleritis can present a diagnostic challenge. It is often the sole initial manifestation of an occult systemic problem. Treatment-resistant scleritis should raise the suspicion of an infectious or malignant masquerade.

Anti-Ro/SSA antibodies in rheumatoid arthritis: clinical and immunologic associations

OBJECTIVE

To assess the prevalence of anti-Ro/SSA in RA and to analyse clinical and serological features of anti-Ro/SSA positive patients with RA.

METHODS

195 consecutive patients affected by RA were studied by counterimmunoelectrophoresis and ELISA for the detection of anti-Ro/SSA antibodies. Anti-Ro were found in 12 patients, with a prevalence of 6%. These 12 patients were pooled with other 15 patients known to have anti-Ro/SSA antibodies and RA, in order to evaluate their clinical and laboratory features.

RESULTS

Anti-Ro positive patients showed a common pattern of joint involvement at onset and a comparable progression of disease compared to anti-Ro negative subjects. In addition, extra-articular manifestations (such as xerophthalmia, xerostomia, scleritis, oral ulcers and amyloidosis) and peculiar autoantibody profile (hypergammaglobulinemia, anti-dsDNA and AMA) were found significantly associated to anti-Ro/SSA positivity. Even though DMARDs withdrawals were more frequently detected in anti-Ro/SSA patients, especially when using gold salts, no statistical difference between the two groups was detected. In addition, anti-TNFalpha treatment did not cause further progression of autoimmunity neither on laboratory nor on clinical ground.

CONCLUSION

Anti-Ro/SSA can be detected in about 6% of patients affected by RA. These patients presented a peculiar clinical picture characterised by extra-articular manifestations some of which are known to be anti-Ro/SSA correlated, while others are more disease-specific (amyloidosis, episcleritis). Anti-Ro/SSA are significantly associated with other autoantibodies not specific for RA such as anti-dsDNA and AMA. Treatment with anti-TNF drugs did not cause further progression of autoimmunity neither on laboratory nor on clinical ground.

Atypical Pneumococcal Scleritis After Pterygium Excision

PURPOSE

To describe an unusual case of pneumococcal scleritis after pterygium excision and to review the literature on infectious scleritis associated with pterygium excision.

METHODS

Case report and literature review.

RESULTS

A 58-year-old white man underwent excision of a nasal pterygium of the right eye. Two weeks postoperatively, the patient developed an infectious scleritis caused by Streptococcus pneumoniae. The scleritis was complicated with hypopyon and a scleral necrosis area 6 mm away from the superior limbus with a positive Seidel test. Topical and systemic antibiotics resolved the case without any surgical procedures.

CONCLUSION

Streptococcus pneumoniae must be considered as a possible agent in cases of necrotizing scleritis associated with pterygium excision.

[Inflammatory glaucomas]

The prevalence of glaucoma in patients with intra- or extraocular inflammation is five to twenty percent. The etiopathogenesis is manifold, including classical secondary open and closed angle mechanisms as well as specific inflammatory elements. Diagnosis and follow-up studies of inflammatory glaucomas are often difficult. The therapeutic options are limited or are poorly evaluated. The development of a secondary glaucoma is a severe complication of intra- or extraocular inflammation and may even lead to blindness. Further investigations, especially with regard to the treatment of inflammatory glaucomas, are necessary to improve the prognosis.

Posterior scleritis secondary to Pseudomonas aeruginosa keratitis

PURPOSE

To report a case of Pseudomonas aeruginosa keratitis that progressed to posterior scleritis.

METHODS

Observational case report.

RESULTS

A 64-year-old woman was treated for P. aeruginosa keratitis. Twelve days later, she was diagnosed with posterior scleritis and treated with oral ciprofloxacin. Her condition progressed, ultimately resulting in enucleation. Histopathology confirmed posterior scleritis, a previously unreported complication of P. aeruginosa keratitis.

CONCLUSION

P. aeruginosa keratitis may progress to posterior scleritis, a potentially devastating complication.

Scedosporium prolificans sclerokeratitis 10 years after pterygium excision with adjunctive mitomycin C

Scedosporium prolificans is an unusual infection, especially following pterygium surgery. A 63-year-old man who developed an uncomfortable, red right eye 10 years after pterygium surgery with adjunctive mitomycin C is described. To the best of the authors' knowledge, this is the first reported case of S. prolificans sclerokeratitis following pterygium surgery with adjunctive mitomycin C.

Surgically induced necrotizing scleritis occurring 48 years after strabismus surgery

We present a 52-year-old woman who was diagnosed with surgically induced necrotizing scleritis 48 years after strabismus surgery. This case demonstrates the importance of a high index of suspicion for this sight-threatening condition, even many years after strabismus surgery.

Clinicopathologic case report: scleral buckle associated nontuberculous mycobacterial scleritis

Nontuberculous mycobacterial (NTM) infections have become increasingly important in ophthalmology, particularly with keratorefractive surgery. We report a case of scleral buckle associated NTM scleritis occurring in a 69-year-old male after silicone sponge explant removal. Purulent scleral ulceration with nodule formation persisted despite topical antimicrobial therapy, buckle removal, and surgical debridement. Eventually, tissue biopsy revealed noncasseating granulomas with acid-fast bacilli that were identified in culture as Mycobacterium chelonae. The infection resolved only after administration of systemic antibiotics. NTM are important pathogens in scleral buckle associated scleritis and should be considered in persistent cases. Surgical therapy remains the cornerstone of therapy, but antimicrobials, particularly newer fourth generation fluoroqunilones, may have an important role in treating scleral buckle associated NTM scleritis.

Myositis and scleritis associated with Behcet's disease: an atypical presentation

We report a case of an 18-year-old female, who was diagnosed as having systemic Behcet's disease with chief complaints of vision loss in the right eye and redness and pain in both eyes. In addition to an anterior necrotizing scleritis, she had several attacks of retrobulbar neuritis and lateral rectus myositis. She responded well to i.v. and topical prednisolone and her subsequent attacks were treated with i.v. cyclophosphamide (500 mg on presentation and on Days 7, 10, 12, 15, and 20; the cycle was repeated every 20 days). She benefited on this treatment and her vision improved dramatically. Her final acuity of 20/50 was thought to be due to presumed previous attacks of optic neuritis and anterior segment inflammation. During the five-month follow-up period, she had no other attacks. Ischemia and inflammation are common in Behcet's disease and sometimes thrombosis and vasculitic changes may cause a decrease in vision. In this case, the immunosuppressive therapy helped attenuate the inflammatory vasculitic episodes during the disease course.

Lymphome oculaire de type MALT simulant une sclérite ou une uvéite postérieure

PURPOSE

Diagnostic and therapeutic management of masquerade syndromes associated with MALT-type lymphoma.

PATIENTS AND METHOD

We report the cases of three patients referred for acute or chronic severe loss of visual acuity. All of them suffered from uveitis or scleritis resistant to corticoid treatment. Each one had posterior uveitis associated with retinochoroidal infiltration, anterior scleritis associated with uveal effusion syndrome, or bilateral pan-uveitis associated with serous retinal detachment. Two patients had medical records of systemic malignancies. They underwent an extensive work-up. Search for an infectious, immune or malignant disease was negative but orbital imaging showed a posterior scleral thickening in all cases.

RESULTS

Diagnosis of mucosa-associated lymphoid tissue (MALT) ocular lymphoma was assessed in all cases after scleral biopsy. Immunohistochemical analysis showed CD20(+) and CD5(-) scleral lymphocyte infiltrates. The three patients underwent chemotherapy associated with radiotherapy. Lesions were stabilized in the first case, whereas six lines of visual acuity improvement was noted in the second one, and full recovery was achieved after treatment in the third case.

DISCUSSION

Clinical manifestations of this ocular lesion seem to be multiple, masquerading as different types of posterior uveitis or scleritis. In the three cases, we did found other systemic locations of MALT-type lymphoma. Diagnosis was mainly based on pathological analysis. Fast visual recovery in two cases demonstrated the importance of an early diagnosis and a specific treatment. All cases of chronic and corticoid-resistant posterior uveitis require a specialized radiological evaluation followed, if necessary, by multiple orbital biopsies.

Aspergillus flavusScleritis: successful treatment with voriconazole and caspofungin

Aspergillus scleritis is a potentially devastating ocular infection difficult to treat because of poor scleral vascularity. Most Aspergillus cases occur following ocular surgery, but others have been associated with trauma or intravenous drug use. No anti-fungal agents are consistently efficacious in the treatment of scleral fungal infections. We report a case of Aspergillus scleritis successfully treated with a combination of voriconazole and caspofungin, as well as a review of the literature concerning treatment of Aspergillus scleritis.

[Posterior scleritis--diagnostic difficulties--a case report]

We present a patient with pain and trouble vision in her right eye, we want to show how difficult it is to diagnose a posterior scleritis before any complication might occur. Diagnosis was established by ocular ultrasound. Treatment included steroids for several months.

[Posterior scleritis--a case report]

Authors present clinical manifestation and therapeutic possibilities in posterior scleritis, a disease, which may cause diagnostic dilemma. They also give an account of new examination methods which amend the diagnostic schema and safely confirm this diagnosis. In the article, a disease of a seventeen years old man is presented, in which posterior scleritis of unknown etiology was diagnosed. Following the systemic corticosteroid treatment the visual acuity of the affected eye improved, subjective signs disappeared, and the clinical manifestation returned to normal.