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Sood S, Du J, Chen A, Medina A, Do BK. Segmental retinal arteritis in a case of presumed bilateral rifabutin-associated hypopyon uveitis. Am J Ophthalmol Case Rep 2024; 36:102170. [PMID: 39314249 PMCID: PMC11417556 DOI: 10.1016/j.ajoc.2024.102170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 08/07/2024] [Accepted: 09/04/2024] [Indexed: 09/25/2024] Open
Abstract
Purpose To describe the presentation and clinical course of bilateral hypopyon uveitis and subsequently diagnosed segmental retinal arteritis in an immunocompromised patient treated with intravitreal and systemic antibiotics while on rifabutin therapy for pulmonary tuberculosis (TB). Observations A 63-year-old female from West Africa with a past medical history of HIV/AIDS, hepatitis B, and pulmonary TB presented with pain and acute vision loss in the left eye for two days. She was compliant with her treatment regimen for HIV and maintenance therapy for TB including rifabutin. Ocular examination revealed hypopyon uveitis in the left eye (OS). She was treated with broad spectrum systemic antimicrobials, topical prednisolone acetate, and intravitreal injections of vancomycin, ceftazidime, voriconazole, and ganciclovir, with resolution of hypopyon OS in 3 days. Aqueous sampling and systemic workup were unrevealing for causative infection. Two weeks later, she returned with a nearly identical presentation in the right eye (OD) with hypopyon uveitis and was again treated with intravitreal antibiotics. Anterior segment inflammation OD quickly improved after initiation of topical prednisolone acetate 1 % to reveal segmental retinal arteritis on fundus examination. As aqueous sampling was negative for infectious causes, she was diagnosed with presumed rifabutin associated-hypopyon uveitis in both eyes (OU) and segmental retinal arteritis OD, which has not been described previously with rifabutin use. Rifabutin was discontinued and there were no recurrences of uveitis over nine months of follow-up. Conclusions and importance/implications Uveitis is an uncommon dose-related toxicity of rifabutin therapy. Segmental retinal arteritis (SRA) may be a rare finding when there is posterior segment involvement, especially in patients with concurrent TB infection. This report highlights a case of delayed bilateral hypopyon-uveitis and expands the presentation to include SRA. Patients treated with rifabutin should be counseled on signs and symptoms of uveitis. Development of rifabutin-associated uveitis may require medication discontinuation.
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Affiliation(s)
- Shefali Sood
- Department of Ophthalmology, Medstar Washington Hospital Center/Georgetown University Hospital, 110 Irving St NW, Washington DC, 20010, USA
| | - Jeanette Du
- Department of Ophthalmology, Medstar Washington Hospital Center/Georgetown University Hospital, 110 Irving St NW, Washington DC, 20010, USA
- The Retina Group of Washington, 5454 Wisconsin Ave Suite 650, Chevy Chase, MD, 20815, USA
| | - Allison Chen
- Wright State University Boonshoft School of Medicine, 3640 Colonel Glenn Hwy, Fairborn, OH, 45324, USA
| | - Andy Medina
- Department of Ophthalmology, SUNY Buffalo School of Medicine, 955 Main St, Buffalo, NY, 14203, USA
| | - Brian K. Do
- Department of Ophthalmology, Medstar Washington Hospital Center/Georgetown University Hospital, 110 Irving St NW, Washington DC, 20010, USA
- The Retina Group of Washington, 5454 Wisconsin Ave Suite 650, Chevy Chase, MD, 20815, USA
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Putera I, Ten Berge JCEM, Thiadens AAHJ, Dik WA, Agrawal R, van Hagen PM, La Distia Nora R, Rombach SM. Relapse in ocular tuberculosis: relapse rate, risk factors and clinical management in a non-endemic country. Br J Ophthalmol 2024:bjo-2024-325207. [PMID: 38609164 DOI: 10.1136/bjo-2024-325207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/29/2024] [Indexed: 04/14/2024]
Abstract
AIMS To assess the risk of uveitis relapse in ocular tuberculosis (OTB) following clinical inactivity, to analyse clinical factors associated with relapses and to describe the management strategies for relapses. METHODS A retrospective study was conducted on a 10-year patient registry of patients with OTB diagnosed at Erasmus MC in Rotterdam, The Netherlands. Time-to-relapse of uveitis was evaluated with Kaplan-Meier curve and risk factors for relapses were analysed. RESULTS 93 OTB cases were identified, of which 75 patients achieved clinical inactivity following treatment. The median time to achieve uveitis inactivity was 3.97 months. During a median follow-up of 20.7 months (Q1-Q3: 5.2-81.2) after clinical inactivity, uveitis relapse occurred in 25 of these 75 patients (33.3%). Patients who were considered poor treatment responders for their initial uveitis episode had a significantly higher risk of relapse after achieving clinical inactivity than good responders (adjusted HR=3.84, 95% CI: 1.28 to 11.51). 13 of the 25 relapsed patients experienced multiple uveitis relapse episodes, accounting for 78 eye-relapse episodes during the entire observation period. Over half (46 out of 78, 59.0%) of these episodes were anterior uveitis. A significant number of uveitis relapse episodes (31 episodes, 39.7%) were effectively managed with topical corticosteroids. CONCLUSIONS Our results suggest that approximately one-third of patients with OTB will experience relapse after achieving clinical inactivity. The initial disease course and poor response to treatment predict the likelihood of relapse in the long-term follow-up. Topical corticosteroids were particularly effective in relapse presenting as anterior uveitis.
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Affiliation(s)
- Ikhwanuliman Putera
- Department of Ophthalmology, Faculty of Medicine, University of Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia
- Department of Ophthalmology, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Department of Internal Medicine Section Allergy and Clinical Immunology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | | | - Alberta A H J Thiadens
- Department of Ophthalmology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Willem A Dik
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Rupesh Agrawal
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
- Lee Kong Chian School of Medicine, Nanyang Technological University of Singapore, Singapore
- Duke NUS Medical School, Singapore
| | - P Martin van Hagen
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Department of Internal Medicine Section Allergy and Clinical Immunology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Rina La Distia Nora
- Department of Ophthalmology, Faculty of Medicine, University of Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Saskia M Rombach
- Department of Internal Medicine Section Allergy and Clinical Immunology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Putera I, van Daele PLA, ten Berge JCEM, Dik WA, La Distia Nora R, van Hagen PM, Rombach SM. Long-term follow-up after treatment of tubercular uveitis: case series and review of the literature. FRONTIERS IN OPHTHALMOLOGY 2023; 3:1270948. [PMID: 38983011 PMCID: PMC11182287 DOI: 10.3389/fopht.2023.1270948] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/03/2023] [Indexed: 07/11/2024]
Abstract
Introduction There is a scarcity of long-term follow-up data and management strategies for recurrent uveitis in tubercular uveitis (TBU), especially in cases extending beyond 10 years after the completion of initial antitubercular treatment (ATT). Methods This retrospective study involved five TBU patients who were initially treated with a combination of four-drug ATT for 6 months, and the five of them had more than 10 years of follow-up after uveitis resolution upon ATT completion. We describe the occurrence of recurrent uveitis and present our approach to managing these recurrent episodes. Results Recurrent uveitis and cystoid macular edema (CME) developed in three out of five included TBU patients with a median of 18 years (range 13-20 years) of follow-up. The anatomical sites of the recurrences were anterior, intermediate, and pan-uveitis. The recurrent episodes varied from 6 years to 15 years after ATT completion. Systemic or local corticosteroids/immunosuppressants successfully resolved all recurrent episodes, but one was also treated with the combination of isoniazid monotherapy again. Two patients needed anti-tumor necrosis factor-α therapy. Conclusion Long-term monitoring of TBU patients after ATT completion is warranted. Further well-designed studies with larger sample sizes are required to better estimate the risk of recurrences, investigate the underlying mechanism of recurrences, and identify biomarkers that predict who is at risk for recurrences.
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Affiliation(s)
- Ikhwanuliman Putera
- Department of Ophthalmology, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus University Medical Center, Rotterdam, Netherlands
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Ophthalmology, Faculty of Medicine, Universitas Indonesia – Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Paul L. A. van Daele
- Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Willem A. Dik
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Rina La Distia Nora
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Ophthalmology, Faculty of Medicine, Universitas Indonesia – Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - P. Martin van Hagen
- Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus University Medical Center, Rotterdam, Netherlands
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Saskia M. Rombach
- Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Internal Medicine and Immunology, Rotterdam Eye Hospital, Rotterdam, Netherlands
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Soni D, Karkhur S, Sharma B. Distinct recurrence pattern in a case of bilateral tubercular posterior uveitis: reporting a unique clinical morphology and management challenge. BMJ Case Rep 2021; 14:14/6/e241894. [PMID: 34162610 DOI: 10.1136/bcr-2021-241894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Intraocular tuberculosis has protean clinical manifestations and remains an important etiological differential for uveitis in an endemic region. A 27-year-old male presented with visual acuity of counting fingers close to face in right (OD) and 20/25 in left eye (OS). Examination revealed a choroidal granuloma in OS and healed serpiginous-like choroiditis in OD. Antitubercular therapy was started with systemic corticosteroids. Granuloma resolved completely; however, the patient presented with neuroretinitis and posterior scleritis, as first and second recurrence, respectively, within a oneyear period. These were managed with systemic corticosteroids and immunosuppressive therapy was added, after second recurrence. The patient responded well and maintains remission. This case presented a clinical challenge with distinct recurrence patterns of tubercular posterior uveitis in the same eye, which has not been reported before. Successful management entailed use of antitubercular therapy, corticosteroids, and immunosuppressive therapy in a step-ladder approach, resulting in preservation of vision and achieving long-term remission.
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Affiliation(s)
- Deepak Soni
- Department of Ophthalmology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Samendra Karkhur
- Department of Ophthalmology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Bhavana Sharma
- Department of Ophthalmology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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