Vitrectomy Combined with Repeated Intravitreal Injection of Ceftazidime for the Treatment of Brucellosis Endophthalmitis: A Case Report and Literature Review

PURPOSE

To present a treatment regimen for Brucellosis endophthalmitis that resulted in a good visual outcome. Additionally, we conducted a literature review on the treatment and visual prognosis of related cases.

CASE PRESENTATION

A 49-year-old woman with the chief complaint of decreased vision and redness in the right eye was initially diagnosed with noninfectious uveitis and prescribed high-dose steroids which led to transient improvement followed by a decline in vision. An infectious cause was suspected. Metagenomic next-generation sequencing of vitreous fluid and serological testing confirmed Brucella melitensis infection. The patient underwent vitrectomy combined with six intravitreal injections of ceftazidime in the right eye in addition to systemic antibiotic treatment. The intraocular inflammation was completely resolved, and the visual acuity recovered to 20/25, which is the best-documented recovery in Brucella endophthalmitis cases, as revealed by the literature review.

CONCLUSION

Vitrectomy combined with repeated intravitreal injections of ceftazidime can enhance the treatment for brucellosis endophthalmitis and achieve a better visual prognosis.

Revealing Academic Evolution and Frontier Pattern in the Field of Uveitis Using Bibliometric Analysis, Natural Language Processing, and Machine Learning

PURPOSE

Numerous uveitis articles were published in this century, underneath which hides valuable intelligence. We aimed to characterize the evolution and patterns in this field.

METHODS

We divided the 15,994 uveitis papers into four consecutive time periods for bibliometric analysis, and applied latent Dirichlet allocation topic modeling and machine learning techniques to the latest period. .

RESULTS

The yearly publication pattern fitted the curve: 1.21335x2 - 4,848.95282x + 4,844,935.58876 (R2 = 0.98311). The USA, the most productive country/region, focused on topics like ankylosing spondylitis and biologic therapy, whereas China (mainland) focused on topics like OCT and Behcet disease. The logistic regression showed the highest accuracy (71.6%) in the test set.

CONCLUSION

In this century, a growing number of countries/regions/authors/journals are involved in the uveitis study, promoting the scientific output and thematic evolution. Our pioneering study uncovers the evolving academic trends and frontier patterns in this field using bibliometric analysis and AI algorithms.

Infectious eye disease in the 21st century-an overview

Infectious diseases affecting the eye often cause unilateral or asymmetric visual loss in children and people of working age. This group of conditions includes viral, bacterial, fungal and parasitic diseases, both common and rare presentations which, in aggregate, may account for a significant portion of the global visual burden. Diagnosis is frequently challenging even in specialist centres, and many disease presentations are highly regional. In an age of globalisation, an understanding of the various modes of transmission and the geographic distribution of infections can be instructive to clinicians. The impact of eye infections on global disability is currently not sufficiently captured in global prevalence studies on visual impairment and blindness, which focus on bilateral disease in the over-50s. Moreover, in many cases it is hard to differentiate between infectious and immune-mediated diseases. Since infectious eye diseases can be preventable and frequently affect younger people, we argue that in future prevalence studies they should be considered as a separate category, including estimates of disability-adjusted life years (DALY) as a measure of overall disease burden. Numbers of ocular infections are uniquely affected by outbreaks as well as endemic transmission, and their control frequently relies on collaborative partnerships that go well beyond the remit of ophthalmology, encompassing domains as various as vaccination, antibiotic development, individual healthcare, vector control, mass drug administration, food supplementation, environmental and food hygiene, epidemiological mapping, and many more. Moreover, the anticipated impacts of global warming, conflict, food poverty, urbanisation and environmental degradation are likely to magnify their importance. While remote telemedicine can be a useful aide in the diagnosis of these conditions in resource-poor areas, enhanced global reporting networks and artificial intelligence systems may ultimately be required for disease surveillance and monitoring.

Ocular Involvement in Patients with Brucellosis: A Single-Center Prospective Study

PURPOSE

The aim of this study was to evaluate the prevalence, type and treatment outcomes of ocular involvement in patients with brucellosis.

METHODS

This prospective, single-center study enrolled patients admitted to the infectious disease outpatient clinic with diagnosed brucellosis between July 15, 2022 and July 15, 2023. Diagnosis was based on clinical symptoms and a standard Brucella tube agglutination test (≥1/160) or a positive blood culture. Ophthalmologic examinations were performed at baseline and in the first month of treatment. Third and sixth month follow-up examinations were also performed for patients with ocular findings.

RESULTS

Ocular involvement occurred in 60 (24.8%) of 242 patients. Conjunctivitis was the most common ocular involvement and was observed in 39 patients (16.1%). Uveitis was the second most common ocular involvement in 14 patients (5.8%). Scleritis was the least common ocular involvement and was observed in only one patient. Patients with ocular involvement were older (p = 0.027) and had higher rates of weight loss and spondylodiscitis (p = 0.044 and 0.001, respectively). Among laboratory parameters, erythrocyte sedimentation rate and lactate dehydrogenase levels were significantly higher in patients with ocular involvement (p = 0.001 and 0.036, respectively). There were no significant differences in other demographic, clinical, and laboratory characteristics between patients with and without ocular involvement. In 56 (93.3%) patients, the ocular findings improved during the follow-up examination.

CONCLUSION

Brucellosis, a systemic infection, can manifest with ocular involvement. Early detection and treatment through ophthalmological examination are crucial in managing brucellosis.

Ophthalmic implications of biological threat agents according to the chemical, biological, radiological, nuclear, and explosives framework

As technology continues to evolve, the possibility for a wide range of dangers to people, organizations, and countries escalate globally. The United States federal government classifies types of threats with the capability of inflicting mass casualties and societal disruption as Chemical, Biological, Radiological, Nuclear, and Energetics/Explosives (CBRNE). Such incidents encompass accidental and intentional events ranging from weapons of mass destruction and bioterrorism to fires or spills involving hazardous or radiologic material. All of these have the capacity to inflict death or severe physical, neurological, and/or sensorial disabilities if injuries are not diagnosed and treated in a timely manner. Ophthalmic injury can provide important insight into understanding and treating patients impacted by CBRNE agents; however, improper ophthalmic management can result in suboptimal patient outcomes. This review specifically addresses the biological agents the Center for Disease Control and Prevention (CDC) deems to have the greatest capacity for bioterrorism. CBRNE biological agents, encompassing pathogens and organic toxins, are further subdivided into categories A, B, and C according to their national security threat level. In our compendium of these biological agents, we address their respective CDC category, systemic and ophthalmic manifestations, route of transmission and personal protective equipment considerations as well as pertinent vaccination and treatment guidelines.

An Unusual Manifestation of Brucella-Associated Uveitis in a Young Male Patient

This is a unique case of retinoschisis as an ocular manifestation of brucellosis. A 38-year-old male presented with recurrent episodes of bilateral eye redness, predominately in his left eye. His visual acuity was not affected, and he did not report any other symptoms. On slit lamp examination, binocular Koeppe nodules of the iris and cells in the left anterior chamber were observed. Fundoscopy followed by meticulous multimodal imaging confirmed left inferior retinoschisis. The patient was diagnosed with panuveitis, and a series of laboratory examinations revealed positive anti-IgM Brucella antibodies. Ocular brucellosis can cause variable, atypical, and serious presentations, hence, early diagnosis is paramount to avoid complications.

Ocular Involvement of Brucellosis: A Pooled Analysis Study

AIM

Brucellosis may affect the eye to varying degrees. The aim of this study was to investigate the ocular involvement of brucellosis and highlight key points.

MATERIAL AND METHODS

Published literature in English language on the ocular involvement of brucellosis within last 30 years was evaluated. The PubMed international database was screened using certain keywords.

RESULTS

The study included 27 publications evaluating a total of 159 cases. The most common types of ocular involvement were uveitis (52.2%) and conjunctivitis (17.6%). Most cases had concomitant systemic brucellosis (27.7%), and the most commonly used diagnostic method was a serological test (92.4%). Of all the patients, 37.1% recovered with sequelae.

CONCLUSION

Brucellosis may cause a wide range of ophthalmic manifestations, and an overlooked or late diagnosis may also lead to the development of sequelae or loss of vision. A routine ophthalmologic examination should be performed in all patients with systemic brucellosis.

Pathogenesis of Bacterial Uveitis

PURPOSE

To describe the pathogenesis and the general immune mechanisms of the most frequent causes of bacterial uveitis.

METHODOLOGY

Narrative review.

RESULTS

Both extra- and intracellular bacteria can induce uveitis, whereas intracellular bacteria are generally transported into the inner eye via cells of the innate immune system, mainly macrophages. Systemic adaptive immunity is usually induced before the bacteria are localized to the inner eye, and once T and B cells have detected the pathogens behind the blood-eye barriers they elicit an acute and/or chronic inflammatory response deteriorating visual acuity that can severely affect the non-regenerating, intraocular tissues.

CONCLUSIONS

An understanding of pathogenic mechanisms, and its correlation with clinical and imaging features, can facilitate early recognition of microbial factors and institution of appropriate therapy.

Ophthalmological findings in brucellosis

PURPOSE

To evaluate the ophthalmological findings in patients diagnosed with acute, subacute or chronic brucellosis and to determine the effects of this disease on ocular structures.

METHODS

Eighty-seven patients diagnosed with brucellosis and 71 healthy cases (as a control group) were enrolled in this prospective study. All participants underwent a complete ophthalmic evaluation, including slit lamp biomicroscopic examination, Goldman applanation tonometry, specular microscopy, optical coherence tomography and fundoscopy with pupil dilation.

RESULTS

Overall, ocular involvement was present in 47 eyes of 27 (31.03%) patients diagnosed with brucellosis and was most common in the chronic brucellosis group. In the acute brucellosis group, papillary conjunctivitis in 8 eyes of 4 patients and anterior uveitis in 10 eyes of 6 patients were noted. In the subacute brucellosis group, papillary conjunctivitis in 4 eyes of 2 patients and sequelae of anterior uveitis in 6 eyes of 3 patients were observed. In the chronic brucellosis group, panuveitis in 4 eyes of 2 patients, choroiditis in 4 eyes of 2 patients, and signs of previous anterior uveitis in 11 eyes of 6 patients were noted. Visual acuity was significantly worse in patients with acute anterior uveitis (AAU) or previous anterior uveitis (PAU) compared with the control cases.

CONCLUSION

Ocular involvement should be kept in mind in patients with brucellosis, especially acute, and brucellosis should be included in the differential diagnosis of patients with anterior uveitis living in endemic areas, since the clinical presentation of the disease may not be overt.

Research progress on complications of Brucellosis

Brucellosis is a common zoonotic disease that is widely spread worldwide and poses a major threat to human health. Clinically, it often presents with non-specific symptoms such as fever, excessive sweating, malaise, myalgia, arthralgia, loss of appetite, weight loss, and enlarged liver, spleen and lymph nodes. The disease has a long and recurrent course, often accumulating in multiple systems and organs. Of these, osteoarticular involvement is the most common complication, with a prevalence of approximately 2-77%, usually manifesting as spondylitis, sacroiliac arthritis and peripheral arthritis. Hepatosplenomegaly is seen in about 50% of patients with brucellosis, and gastrointestinal disturbances such as abdominal pain, nausea, and vomiting are common. Although respiratory involvement is less common, pneumonia, pleurisy, pleural effusion, and pulmonary nodules have been reported. Besides, approximately 2-20% of cases involve infections of the male genitourinary system, mainly manifesting as unilateral epididymal-orchitis and orchitis. The most serious complication facing brucellosis is cardiovascular involvement, and although the overall mortality rate of brucellosis is about 1% and the incidence of brucellosis endocarditis is less than 2%, more than 80% of deaths are associated with endocarditis. Furthermore, brucellosis is complicated by hematologic disease, with anemia occurring in approximately 20-53% of children during the acute phase. In addition, the neurological incidence of brucellosis is about 0.5-25%, mainly manifested as meningitis. In this study, we review the multisystem complications of brucellosis with the aim of improving early diagnosis, timely treatment and prevention of long-term complications.

Case report: Brucellosis with rare multiple pulmonary nodules in a depressed patient

Background

Brucellosis is a zoonotic disease that threatens public health and creates an economic burden. Unfortunately, it is often overlooked in developing countries, with misdiagnosis causing negative impacts on those with low income. Although the symptoms of brucellosis are commonly reported as fever and fatigue, rare pulmonary, and psychiatric involvements should also be considered. We present the first brucellosis patient in China with multiple pulmonary nodules and depression. Furthermore, this report highlights the importance of collecting patient history in epidemic areas of brucellosis.

Case presentation

We report the case of a 40-year-old woman with intermittent fever for 2 months and gradually accompanied by chills, dry cough, arthralgia, and fatigue. The patient was also diagnosed with depression after fever. She received symptomatic treatment at a regional hospital; however, there was no significant symptom relief. She suddenly developed hemoptysis 1 day prior to arrival at our hospital, where we discovered that her liver, spleen, neck, and axillary lymph nodes were enlarged, and there were multiple nodules in both lungs. The patient was eventually diagnosed with brucellosis after the serum agglutination test and received antibiotic therapy, which provided symptom relief.

Conclusion

This report describes a case of brucellosis with uncommon multipulmonary nodules and depression in China. This study has widened the evidence of respiratory involvement due to brucellosis. Second, it demonstrates the importance of collecting a comprehensive medical history, especially in epidemic areas. In conclusion, for febrile patients with pulmonary nodules and depression, especially in endemic areas, brucellosis should be considered.

Ocular Lesions in Brucella Infection: A Review of the Literature

Ocular lesions due to Brucella infection are uncommon and easily overlooked in clinical management, but must be differentiated from non-infectious eye diseases and treated promptly to protect the patient's vision. We reviewed the relevant literature and identified 47 patients with ocular complications of Brucella infection. Among them, 28 showed ocular neuropathy, 15 presented with uveitis, and four patients displayed other ocular symptoms. Ocular symptoms accompanying Brucella infection require prompt diagnosis and treatment. The main methods of diagnosis are intraocular fluid tests and blood tests. Early diagnosis and treatment with suitable antibiotics are central to protecting the patient's vision. Notably, in terms of mechanism of injury, Brucella infection is chronic and cannot be eliminated by phagocytes, and can cause damage to the eye by inducing autoimmune reactions, antigen-antibody complex production, release of endogenous and exogenous toxins, and bacterial production of septic thrombi in the tissues. In this review, we summarize the ocular symptoms, diagnosis, treatment and prognosis of Brucella infection, and discuss the mechanisms of Brucella in ocular lesions, providing a reference for the diagnosis and treatment of Brucella ocular lesions.

Brucelosis como causa de fiebre persistente en un trabajador de la salud de Cali, Colombia. Reporte de caso

Introducción. La brucelosis es la principal zoonosis a nivel mundial. Es transmitida al ser humano principalmente por el consumo de productos no pasteurizados, así como por exposición ocupacional. Las manifestaciones son inespecíficas lo que conlleva a un reto diagnóstico para el clínico, siendo una de las causas que pueden   explicar la fiebre de origen desconocido y la cual no se tiene como etiología relevante dado su poca incidencia en nuestro medio, dejándose como una patología probable una vez se tengan descartadas las enfermedades más frecuentes y prevalentes. Resumen del Caso. Resumen del caso: Presentamos a un hombre joven trabajador del área de la salud con antecedente de queratocono y urolitiasis quien ingresó al servicio de urgencias por cuadro febril agudo asociado a cefalea, mialgias y artralgias con sospecha inicial de infección por dengue. Sin embargo, dada la persistencia de la fiebre por más de 96 horas tras realizarse múltiples estudios negativos y múltiples consultas al servicio de urgencias requiriendo vigilancia de forma estricta, y bajo la sospecha epidemiológica de posible cuadro de zoonosis, se consideró realizar pruebas de detección para brucelosis mediante aglutinación por antígenos febriles siendo positivo para B. abortus en títulos altos de 1:160. Se corroboraron los hallazgos mediante prueba de aglutinación por rosa de Bengala y finalmente con inmunoensayo enzimático (ELISA) con resultado positivo para IgM e IgG. Se dio tratamiento con rifampicina y doxiciclina por 6 semanas con mejoría completa sin recurrencia. Discusión. La brucelosis puede presentarse como un cuadro febril inespecífico que si bien es muy poco frecuente en nuestro medio debe tenerse como probabilidad etiológica dado el área rural y las pocas medidas de vigilancia epidemiológica y de salubridad en el adecuado proceso de pasteurización aún en proceso de Industrialización. En este reporte mostramos que la sospecha clínica y el uso de ayudas diagnósticas de detección indirectas permitieron hacer el diagnóstico sin que estas sean las de mejor rendimiento dada su baja especificidad y posibilidad de estar presentes en múltiples procesos infecciosos, pero en el caso de este paciente fue la clave para lograr el origen de la fiebre de origen desconocido.  Si bien la mortalidad es baja, la terapia antibiótica combinada reduce la recurrencia y las complicaciones asociadas.

Metagenomic Next-Generation Sequencing to Investigate Infectious Endophthalmitis of Brucella: A Case Report

Introduction

Brucellosis is a systemic disease that exists prevalently in clinical manifestations. The symptoms present in organs such as the eyes (in ocular brucellosis) can lead to misdiagnosis or even failure to diagnose. Metagenomic Next-Generation Sequencing (mNGS), a high-throughput sequencing approach, could be applied for the detection of microorganisms.

Case Presentation

A 57-year-old female with acute right-eye vision loss, treated with clindamycin and dexamethasone sodium phosphate for 1.5 months, was difficult to diagnose using regular methods. mNGS was utilized for the aqueous fluid from the patient, and Brucella melitensis was identified. The inflammation was treated with 3 months of antibiotherapy. However, even with specific medicine and surgery, the vision remained poor because severe ocular conditions last for a long time.

Conclusion

It suggests that brucella should still be a probable pathogen in endophthalmitis despite its low incidence in non-epidemic areas. Moreover, mNGS can achieve early diagnosis and timely treatment for difficult-to-diagnose ocular infections.

Recurrent Fevers and Neuro-ophthalmic Disorders in a Mathematical Genius

Horner's syndrome coexisting with an ipsilateral fourth cranial nerve palsy is a rare occurrence and likely localises to pathology in the cavernous sinus. One such case may have occurred in the 18^th century affecting the renowned mathematician Leonhard Euler. A review of his biographies, eulogies, and three finely detailed facial portraits suggest that these two neuro-ophthalmic conditions, along with visual loss and a decades-long intermittent febrile illness, may have been the result of an orbital cellulitis and septic cavernous sinus thrombosis, from an underlying chronic brucellosis infection.

Unusual bilateral panuveitis uveitis with brucellosis

Brucellosis is a zoonotic disease that can be found worldwide. Although it has been eradicated and is under control in most developed countries, it still represents an important health problem in many parts of the world. In this case report, we present a rare unusual findings of a case with panuveitis uveitis secondary to brucellosis.

Choroidal thickness and retinal nerve fiber layer analysis in acute systemic brucellosis

Introduction

This study aims to detect changes in choroidal thickness and retinal nerve fiber layer (RNFL) thickness in acute stage brucellosis.

Methods

Fnewly diagnosed patients with acute brucellosis and 19 healthy individuals as control group were included in the study. Choroidal thickness and RNFL thickness were measured using the Spectral Domain Cirrus OCT Model 400 (Carl Zeiss Meditec, Jena, Germany) for each participant in the patient and control group.

Results

In the brucella group, in the right eyes, the mean nasal choroidal thickness was 272.77 ± 50.26 μm ( p = 0.689), the mean subfoveal choroidal thickness was 321.14 ± 33.08 μm ( p = 0.590), the mean temporal choroidal thickness was 278.86 ± 48.84 μm ( p = 0.478), and the mean RNFL thickness was 90.43 ± 8.93 μm ( p = 0.567). In the left eyes, the mean nasal choroidal thickness was 282.29 ± 48.93 μm ( p = 0.715), the mean subfoveal choroidal thickness was 316.79 ± 39.57 μm ( p = 0.540), the mean temporal choroidal thickness was 284.93 ± 50.57 μm ( p = 0.392), and the mean RNFL thickness was 92.64 ± 8.95 μm ( p = 0.813).

Conclusion

No difference was found between the control and the brucella groups regarding to all choroidal regions and RNFL thickness.

Bilateral serous choroidal detachment in brucellosis and its management and outcome: Literature review and case report

To report an unusual case of a 71-year-old livestock farmer with systemic brucellosis and ocular involvement. Examination showed vitreous haze with bilateral serous choroidal detachment. He was treated with topical antibiotics and corticosteroids, Tab rifampicin 600 mg and doxycycline 100 mg for 6 weeks with visual recovery and complete resolution of serous choroidal detachment in 2 weeks. This is the first case of bilateral serous choroidal detachment in a case of systemic brucellosis. Immune-mediated complex and direct microbial invasion of uveal tissue leading to serous choroidal detachment is the proposed pathogenesis that responds well to topical corticosteroids.

Retinal vasculitis with Chronic Recurrent Multifocal Osteomyelitis: a case report and review of the literature

Background

Concurrent presentation of retinal vasculitis with mixed sclerotic and lytic bone lesions is rare.

Case presentation

We present the case of a 37-year old woman with a several year history of episodic sternoclavicular pain who presented for rheumatologic evaluation due to a recent diagnosis of retinal vasculitis. We review the differential diagnosis of retinal vasculitis, along with the differential diagnosis of mixed sclerotic and lytic bone lesions. Ultimately, bone marrow biopsy confirmed diagnosis of chronic recurrent multifocal osteomyelitis (CRMO). Concurrent presentation of CRMO with retinal vasculitis is extremely rare but important to recognize. The patient demonstrated clinical response to prednisone and tumor necrosis factor-alpha inhibition (TNF-i).

Conclusion

This case reports and unusual presentation of CRMO spectrum disease involving the sternum and sternoclavicular joint with concurrent retinal vasculitis.

Study of serum bactericidal and splenic activity of Total-OMP- CagA combination from Brucella abortus and Helicobacter pylori in BALB/c mouse model

BACKGROUND

Brucella is a Gram-negative and facultative intracellular organism that causes brucellosis, a common zoonotic disease. Over 500,000 people are annually affected by brucellosis. Brucella is highly infectious through inhalation route; for this reason it is used for biological warfare aims. This study aimed to study the serum bactericidal and splenic activity of Total-OMP-r CagA immunogens from Brucella abortus and Helicobacter pylori in a BALB/c mouse model.

METHODS

Immunization of BALB/c mice was performed with immunogenic proteins three times subcutaneously (S.C.) at 14-day intervals. The protective effects of two component vaccines with CpG adjuvant were evaluated after mice were challenged with H. pylori ss1 and Brucella abortus strain 544. The specific IgG1 and IgG2a antibodies in sera were assessed using ELISA test. For measuring the antigen-specific IL-4, IL-12 and IFN-γ responses in sera of immunized mice after challenge, RT-PCR technique was applied. Twenty days after the challenge, mice were killed then gastric, splenic and serum samples were assessed and bacterial colony count was measured based on the pour plate count agar.

RESULTS

The results indicated that rCagA + OMP decreased bacterial colonization in these tissues, and significant difference was observed between test and control groups (p value˂0.001).

CONCLUSION

Our results showed that the combination vaccine was effective against an oral exposure and the bacterial burden in the spleen, serum and gastric tissues were reduced in mice immunized with the Total- OMP-CagA.

Effect of hydroxychloroquine on treatment and recurrence of acute brucellosis: a single-blind, randomized clinical trial

Brucellosis is associated with a high recurrence rate and requires more than one course of standard treatment; therefore, more research is required to find more effective treatments that lead to prompt recovery, and reduce the relapse of disease. This single-blind, randomized study was designed to evaluate the effect of the standard treatment for brucellosis in combination with hydroxychloroquine. A total of 177 patients with acute brucellosis were randomly assigned to one of two treatment groups: doxycycline-streptomycin (DS) and doxycycline-streptomycin-hydroxychloroquine (DSH). Clinical symptoms and signs, serological tests, and side effects of therapy were compared between the two groups during the treatment course and at three and six months after the end of drug therapy. Of the 177 patients, with a mean age of 40.5 ± 16.9 years, 66.1% were males. The mean duration of clinical signs prior to admission was 43.4 ± 41.1 days. Appropriate clinical responses, relapse, treatment failure, and adverse drug reactions were seen in 98.9%, 1.2%, 0.0%, and 12.6% of patients, respectively, in the DSH group vs. 86.7%, 11.6%, 2.3%, and 19.8% of patients, respectively, in the DS group. There were significant differences in clinical response and relapse rates between the two groups. The addition of hydroxychloroquine to a doxycycline-streptomycin regimen appears to increase the efficacy of treatment, accelerate improvement of clinical symptoms, and significantly reduce the rate of relapse of brucellosis.

Endogenous Brucella endophthalmitis: A case report

Brucellosis may be associated with a wide range of ophthalmic manifestations including endophthalmitis, which is a sight-threatening condition that needs to be rapidly recognized and treated to avoid permanent visual loss. A 26-year-old female with a 6-month history of vision loss in the left eye was treated with high dose systemic corticosteroids and azathioprine with an initial misdiagnosis elsewhere. A dense vitreous haze with opacities at the posterior hyaloid and a wide area of retinochoroiditis led to the diagnosis of endogenous endophthalmitis at presentation to us. The vitreous sample and blood cultures demonstrated growth of Brucella melitensis. She received 6 months of systemic antibiotherapy, which resulted in resolution of inflammation; however, visual acuity remained poor due to irreversible damage. Infectious etiology, including brucellosis in endemic countries, has to be considered in the differential diagnosis before administering immunomodulatory therapy in patients with panuveitis of unknown origin.

ENDOGENOUS ENDOPHTHALMITIS CAUSED BY BRUCELLA MELITENSIS

PURPOSE

Brucella is an intracellular gram-negative pathogen that acts as a facultative parasite. B. Melitensis endogenous endophthalmitis is quite rare. We herein report an unusual case of B. melitensis endophthalmitis with a good outcome after appropriate management.

METHODS

A retrospective interventional case report of an 18-year-old boy who had unexplained interrupted fever and malaise for the past 4 months and was being treated as a case of fever of unknown origin. He presented with a 10-day history of pain and loss of vision in the left eye. Visual acuity in the left eye at time of presentation was counting fingers near face. Extensive anterior chamber reaction and flare, as well as, vitritis were found on examination. All blood and urine investigations and radiological imaging were negative.

RESULTS

A diagnostic/therapeutic vitrectomy with antibiotic injection helped in identifying the offending organism and controlling the inflammation. Vitrectomy sample revealed B. melitensis with no sensitive result. Patient recovered vision in his eye to 20/150. Eye examination revealed a quiet eye, with flat retina and some retinal pigment epithelial changes at macula.

CONCLUSION

B. melitensis endophthalmitis is a rarely encountered disease entity. High suspicion and prompt management with vitrectomy and appropriate antibiotic injection was successful in salvaging the patient's eye.

Infectious optic neuropathies: a clinical update

Different forms of optic neuropathy causing visual impairment of varying severity have been reported in association with a wide variety of infectious agents. Proper clinical diagnosis of any of these infectious conditions is based on epidemiological data, history, systemic symptoms and signs, and the pattern of ocular findings. Diagnosis is confirmed by serologic testing and polymerase chain reaction in selected cases. Treatment of infectious optic neuropathies involves the use of specific anti-infectious drugs and corticosteroids to suppress the associated inflammatory reaction. The visual prognosis is generally good, but persistent severe vision loss with optic atrophy can occur. This review presents optic neuropathies caused by specific viral, bacterial, parasitic, and fungal diseases.

Bilateral sacroiliitis and uveitis comorbidity: brucellosis? Ankylosing spondylitis?

We present a rare case of a comorbidity of sacroiliitis and brucellosis infection. A 28-year-old woman received irregular medication due to ongoing backache and hip pain for 5 years. The patient presented to our hospital for evaluation of visual loss and was diagnosed with uveitis. Sacroiliac MRI was performed to investigate the inflammatory backache and hip pain, and the aetiology of the uveitis, revealing the presence of sacroiliitis. The patient's blood test results were as follows: positive brucellosis Rose Bengal test and positive tube agglutination test with a titre of 1/640. The patient was treated with doxycycline and rifampicin for 8 weeks for the brucellosis infection, and with acemetacin for the ankylosing spondylitis. The patient's back and hip pain decreased significantly 8 weeks later; however, the uveitis was not controlled by the treatment. Therefore, anti-tumour necrosis factor (infliximab) treatment was started.

Sex and reproduction in the transmission of infectious uveitis

Current data permit only speculations regarding sex differences in the prevalence of infectious uveitis between women and men because uveitis case surveys do not uniformly report gender data. Differences in prevalence that are reported in the literature could relate to simple differences in the number of women and men at risk for infection or to biological differences between men and women. Compared to other types of uveitis, infectious uveitis may be directly related to occupational exposures or sexual behaviors, which differ between women and men, and may mask actual biological differences in susceptibility to ocular manifestations of the infection and its prognosis. In infectious uveitis for which there is no element of sexual transmission and data is available, prevalence of ocular disease is roughly equal between women and men. Women also have a unique relationship with infectious uveitis in their role as mothers. Vertical transmission of infections such as herpes simplex, toxoplasmosis, and cytomegalovirus can produce severe chorioretinitis in neonates.

Ocular involvement of brucellosis

A 29-year-old male diagnosed with brucellosis a week earlier was referred to the ophthalmology clinic with visual complaints. On examination, visual acuity was 20/25, he had conjunctival injection on slit lamp examination. There was also bilateral optic disk swelling plus retinal hyperemia (optic disc hyperemia and vascular tortuosity) and intraretinal hemorrhage on funduscopy. The patient was admitted and treated with cotrimoxazole, rifampin, doxycycline and prednisolone for 2 months. Ocular manifestations subsided gradually within 6 months after treatment. Brucellosis can affect the eye and lead to serious ocular complications. Early diagnosis and prompt treatment should be considered in endemic areas.

The visual impairment and inscrutable disease of Samuel Johnson

Samuel Johnson, the acclaimed author of the Dictionary of the English Language, survived childhood scrofula with impaired sight and hearing. The cause of his scrofula has been attributed to bovine tuberculosis, but mycobacterial infection does not satisfactorily account for the peculiar features of Johnson's eye disorder or his hearing loss. The subject of numerous biographies, Johnson may have the most scrutinized medical history of all time. Medical detectives, hampered by the vagueness of 18(th)-century diagnosis, suspect that phlyctenular eye disease related to tuberculosis was the reason for his visual impairment. Pediatric brucellosis can also explain childhood scrofula associated with visual and auditory disabilities, but it may be difficult to reconcile any single diagnosis given the uncertainties surrounding Johnson's medical and ocular histories.

Brucellar uveitis: intraocular fluids and biopsy studies

BACKGROUND

Ocular brucellosis is usually diagnosed by clinical criteria and serological tests. Little is known with regard to the ocular immunology of brucellosis and the use of intraocular diagnostic tests. We report retrospectively the laboratory findings of patients with ocular involvement associated with brucellosis.

MATERIALS AND METHODS

Patients with uveitis with no evident etiologic diagnosis were evaluated at the Instituto de Medicina Tropical "Alexander von Humboldt" of the Universidad Peruana Cayetano Heredia and the Hospital Nacional Cayetano Heredia. Patients were tested for brucellosis, tuberculosis, syphilis, toxoplasmosis, toxocariasis, and human T-cell lymphotropic virus-1. Blood and intraocular fluid samples were examined. Patients with a diagnosis of brucellar uveitis were selected as cases and patients with a diagnosis of uveitis of other etiology were included as controls. The Goldmann-Witmer coefficient was determined.

RESULTS

Twelve patients with clinical and laboratory findings suggestive of brucellar uveitis were considered as cases. Seven patients with uveitis of other etiology were selected as controls. Four (33.3%) patients with ocular brucellosis had negative ocular agglutinations and eight (66.7%) had positive agglutinations. No control cases had positive agglutinations for Brucella melitensis. The sensitivity of the test was 66.7% and the specificity 100%. Only one patient had a positive culture for B. melitensis in subretinal fluid. The Goldmann-Witmer coefficient was calculated in six cases of brucellosis uveitis and five uveitis controls. It was highly positive in three patients with ocular brucellosis. Tissue samples showed lymphoplasmacytic infiltrates.

CONCLUSIONS

Intraocular serological tests could be used to support the diagnosis of ocular brucellosis.