Anterior scleritis: three case reports and a review of the literature

Scleromalacia perforans as an early manifestation of late-onset rheumatoid arthritis: a case-based review

Rheumatoid arthritis is a chronic autoimmune disease that can affect different organs beyond the joints. Ocular involvement includes keratoconjunctivitis sicca, peripheral ulcerative keratitis (PUK), episcleritis, scleritis, anterior uveitis, and corneal impairment. The most severe form of scleritis, scleromalacia perforans, is an aggressive ophthalmic manifestation that can potentially lead to blindness, usually occurring in late stages of disease. We report a case of an elderly woman in which this severe ocular manifestation occurred early on disease onset, differing from most of the previously reported cases of scleromalacia perforans. Ocular symptoms started concomitantly with the polyarthritis and other extra-articular manifestations, including rheumatoid nodules and vasculitic skin lesions. Ocular disease progressed due to patient's loss to follow-up, requiring pulse therapy with methylprednisolone. However, despite treatment, right eye enucleation was required due to melting of the corneal patch with uveal exposition. The patient was then treated with rituximab with improvement of systemic disease. The present case reinforces that, although rare, this complication is severe and must be promptly diagnosed and aggressively treated to improve prognosis of ocular and systemic RA.

Frequently Relapsing Anterior Nodular Scleritis as the Initial Presentation of a Lethal Systemic Infection: Disseminated Tuberculosis with HIV Coinfection

Background

Scleritis is a painful inflammatory ocular disease often associated with an underlying systemic illness mostly having an autoimmune aetiology. Tuberculosis usually presents as pulmonary infection, and the ocular presentation is considered to be rare. Case presentation. We present a male who developed prolonged pyrexia following systemic steroids while being investigated for a frequently relapsing anterior scleritis. Biopsy of sclera demonstrated acid-fast bacilli, and histology of sclera and lymph node showed granulomatous inflammation with caseation. Contrast CT demonstrated mediastinal and visceral lymphadenopathy with pulmonary changes suggesting disseminated tuberculosis. Later, Western blot confirmed coinfection with HIV with a CD4 count of 71 cells/mm³. He was treated with antituberculous medications, and then HAART was initiated within two months. He showed good response and showed a partial resolution of scleritis at the end of two months.

Conclusion

Tuberculosis tends to occur in unusual sites when coinfected with HIV. Scleritis is a rare extrapulmonary manifestation of tuberculosis. High degree of suspicion is critical in making diagnosis and commencing early treatment.