Asymptomatic choroidal granulomas in common variable immunodeficiency

HLA-A29 negative Birdshot-like chorioretinopathy associated with common variable immunodeficiency

Purpose

To report the longest ophthalmic follow-up and the associated ocular complications of HLA-A29 negative Birdshot-like chorioretinopathy (BLCR) associated with common variable immunodeficiency (CVID).

Observations

A 22-year-old man known for CVID presented with a 3-month history of decreased visual acuity OS. Funduscopy revealed significant cystoid macular edema OS, as well as optic disk edema and chorioretinal infiltrates without signs of vitritis OU. No infectious, inflammatory or neoplastic etiologies were identified. He subsequently received one dose of intravitreal triamcinolone OS which completely resolved the macular edema. The optic nerve edema persisted despite the addition of intravenous immunoglobulin. His visual acuity was 20/20 OU at the 24th follow-up month.

Conclusion

and importance: To our knowledge, this is the third case of HLA-A29 negative BLCR associated with CVID. It is the first case with long-term follow-up providing, in consequence, the best understanding of the natural history and possible complications of this rare disease. Aggressive systemic treatment, in collaboration with an immunologist, is generally needed to control the ophthalmic complications.

Metachronous Diffuse Large B-Cell Lymphoma and Kaposi Sarcoma of the Right Eyelid and Lacrimal Gland in a Patient with Granulomatous Common Variable Immunodeficiency

PURPOSE

To describe the ophthalmic and histopathological features of a female with granulomatous common variable immunodeficiency (CVID) who presented with upper-lid swelling.

PROCEDURES

The patient underwent a biopsy of the right upper lid/palpebral lacrimal gland with imaging showing a left-sided nasopharyngeal mass, multiple lymph nodes within the mediastinum, bilateral lung nodules and a peritoneal nodule in the right iliac fossa. The right upper-lid swelling progressed and was subject to a second biopsy.

RESULTS

The first right upper-lid biopsy revealed a diffuse large B-cell lymphoma (DLBCL), confirmed with clonal IgH gene rearrangement with PCR. The nasopharyngeal mass and lymph nodes were suspected clinically to be DLBCL. However, a biopsy of the nasopharyngeal mass showed Kaposi sarcoma (KS). The second biopsy of the right upper lid/palpebral lacrimal gland revealed KS with no evidence of DLBCL.

CONCLUSION

This is the first documentation of periocular/orbital metachronous DLBCL and KS in a patient with granulomatous CVID. We discuss the role of fluctuating immunity in CVID to explain the spontaneous regression of the DLBCL and the varying clinical picture.

Orbital follicular hyperplasia in common variable immune deficiency syndrome

Common variable immune deficiency (CVID) is characterized by reduced serum immune globulins and impaired or absent antibody responses. Patients become more susceptible to infections and to lymphoproliferation and granulomatous inflammation. Ophthalmic manifestations of CVID are rare. The authors describe a case of orbital follicular hyperplasia in a 15-year-old girl with CVID syndrome causing proptosis and exposure keratopathy.

Birdshot-like chorioretinopathy in common variable immunodeficiency

PURPOSE

To describe a patient with ocular manifestations secondary to common variable immunodeficiency.

METHODS

A 17-year-old adolescent girl presented with asymptomatic bilateral optic disk edema and chorioretinal infiltrates. These findings were noted during routine follow-up visits for hydroxychloroquine use for lymphoid interstitial pneumonia. She underwent a full ophthalmologic and systemic work-up.

RESULTS

At the age of 13, the patient was diagnosed with common variable immunodeficiency with splenomegaly, lymphadenopathy, and lymphoid interstitial pneumonia. Progressive generalized lymphadenopathy developed thereafter. Since the diagnosis of common variable immunodeficiency, she received monthly intravenous immunoglobulin, systemic corticosteroids and later on, oral hydroxychloroquine. Annual routine screening visits to exclude retinal hydroxychloroquine toxicity were unremarkable until age 17. Unaided visual acuity was 6/5 in both eyes. Slit-lamp examination was normal, whereas fundoscopy revealed bilateral optic disk edema and birdshot-like chorioretinal infiltrates, without signs of vitritis. A bilateral hot disk was seen on fluorescein angiography, but there were no signs of vasculitis. Indocyanine green angiography showed macular and midperipheral choroidal granulomas. A brain magnetic resonance imaging scan revealed no signs of raised intracranial pressure. Human leukocyte antigen-typing was negative for HLA-A29, making birdshot chorioretinopathy highly unlikely. The results of a work-up for sarcoidosis were not typical of that disease. During the past months, a remarkable episode of lacrimal gland swelling with spontaneous recovery was noted.

CONCLUSION

We describe a case of ocular manifestations of common variable immunodeficiency, including asymptomatic bilateral chorioretinal granulomas mimicking birdshot chorioretinopathy, combined with optic nerve sheath infiltration, and lacrimal gland involvement.

[Granulomatous disease in common variable immunodeficiency]

PURPOSE

Common variable immunodeficiency (CVID), defined by defective production of immunoglobulins, is the most common primary immunodeficiency in adulthood requiring a medical follow-up. Repeated bacterial infections and/or autoimmune manifestations and/or benign lymphoproliferation (including follicular hyperplasia and/or granulomatous disease) are the hallmark of the disease. This review aims at describing recent advances in the understanding and treatment of granulomatous disease in CVID.

CURRENT KNOWLEDGE AND KEY POINTS

Clinical features of granulomatous disease in CVID can mimic sarcoidosis, remarkable by the low levels of circulating immunoglobulins. Granulomas may be found in several organs in a single patient, and the main features are pulmonary, lymphoid, cutaneous, hepatic or splenic. The features of CVID is remarkable by the high frequency of autoimmune diseases complicating the immunodeficiency. Some immunological abnormalities have been described in such patients, including lymphopenia, decreased T-cells proliferations to mitogens and antigens. Rare polymorphisms in the gene encoding TNFalpha (Tumor Necrosis Factor) have been identified in CVID patients with granulomatous disease.

FUTURE PROSPECTS AND PROJECTS

The evolution of the disease is severe, particularly when the lung is involved. Treatment consists in immunoglobulins substitution, immunosuppressive agents (corticosteroids, cyclophosphamide) and anti-TNFalpha antibodies. These treatments are difficult to manage in such immunocompromised patients.