Uveitis in HIV-infected patients

Viral Anterior Uveitis: A Practical and Comprehensive Review of Diagnosis and Treatment

Anterior uveitis is the most common type of uveitis worldwide. The etiologies of anterior uveitis can be divided into infectious and non-infectious (idiopathic, autoimmune, autoinflammatory, trauma, and others). The viral pathogens most commonly associated with infectious anterior uveitis include Herpes Simplex Virus, Varicella-Zoster Virus, Cytomegalovirus, and Rubella Virus. Other emerging causes of viral anterior uveitis are West Nile Virus, Human-Immunodeficiency Virus, Epstein-Barr Virus, Parechovirus, Dengue Virus, Chikungunya Virus, and Human Herpesvirus type 6,7, and 8. Early recognition allows prompt management and mitigates its potential ocular complications. This article provides an updated literature review of the epidemiology, clinical manifestations, diagnostic tools, and treatment options for viral anterior uveitis.

Serious fungal diseases in Democratic Republic of Congo - Incidence and prevalence estimates

A literature review was conducted to assess the burden of serious fungal infections in the Democratic Republic of the Congo (DRC) (population 95,326,000). English and French publications were listed and analysed using PubMed/Medline, Google Scholar and the African Journals database. Publication dates spanning 1943-2020 were included in the scope of the review. From the analysis of published articles, we estimate a total of about 5,177,000 people (5.4%) suffer from serious fungal infections in the DRC annually. The incidence of cryptococcal meningitis, Pneumocystis jirovecii pneumonia in adults and invasive aspergillosis in AIDS patients was estimated at 6168, 2800 and 380 cases per year. Oral and oesophageal candidiasis represent 50,470 and 28,800 HIV-infected patients respectively. Chronic pulmonary aspergillosis post-tuberculosis incidence and prevalence was estimated to be 54,700. Fungal asthma (allergic bronchopulmonary aspergillosis and severe asthma with fungal sensitization) probably has a prevalence of 88,800 and 117,200. The estimated prevalence of recurrent vulvovaginal candidiasis and tinea capitis is 1,202,640 and 3,551,900 respectively.Further work is required to provide additional studies on opportunistic infections for improving diagnosis and the implementation of a national surveillance programme of fungal disease in the DRC.

When HIV Immunodeficiency and Heterochromia Confuse the Issue: Recurrent Zoster Uveitis Mistaken for Fuchs' Uveitis

Purpose

We report a case with iris heterochromia misdiagnosed as Fuchs' uveitis which finally turned out to be a unilateral zoster uveitis in an HIV-positive patient.

Case Report

A 45-year old patient was seen for a recurrent right anterior uveitis treated with prednisolone 1% drops BID. The iris of the right eye was hypochromic and atrophic and several small granulomatous keratic precipitates (KPs) were present. After discontinuation of corticosteroid drops, severe uveitis developed with mutton-fat KPs, and laser flare photometry (LFP) increased from 20 to 50.3 ph/ms. He had presented with right zoster ophthalmicus two years earlier and HIV-serology revealed to be positive.

Conclusion

Iris heterochromia is not a good disease-defining criterion for Fuch's uveitis even when typical KPs are present and can lead to misdiagnosis. More reliable criteria including stellate KPs, low LFP values, absence of synechiae, vitreitis, and disc hyperfluorescence, all absent in this case, should be sought to confirm or exclude the diagnosis.

Virus-Induced Anterior Uveitis (VIAU) in Immunocompromised Patients

PURPOSE

To describe the clinical characteristics, diagnosis, and treatment of VIAU in immunocompromised patients.

METHODS

A critical review of literature was performed.

RESULTS

Diagnosis and treatment of VIAU in immunocompromised patients may be a challenge due to atypical clinical-courses, severe presentations, and more frequent recurrences. A conclusive diagnosis can be made by aqueous-humour PCR-analysis. Visual prognosis depends on early diagnosis and prompt treatment. Frequent ocular examinations are recommended in HIV patients with CD-4-counts below 100 in order to rule out opportunistic ocular coinfections. It is essential to bear in mind the potential side-effects of therapeutic interventions and consider the possibility of Immune Recovery Uveitis (IRU) in eyes with treated viral retinitis after the initiation of HAART.

CONCLUSIONS

Early diagnosis and treatment of VIAU in immunocompromised patients can be achieved with high suspicion, recognizing clinical features, and obtaining specimens for molecular diagnostic testing in order to avoid usually severe ocular morbidity.

The Etiology of Intraocular Inflammation in HIV Positive and HIV Negative Adults at a Tertiary Hospital in Cape Town, South Africa

PURPOSE

To describe the patterns of uveitis in South Africa.

METHODS

Prospective cross-sectional study.

RESULTS

One hundred and six patients were enrolled and 37.7% had human immune-deficiency virus (HIV) infection. Anterior and panuveitis occurred most frequently. Infectious, non-infectious and idiopathic uveitis were diagnosed in 66.0%, 17.0% and 17.0% of all cases, respectively. Eighty percent of HIV+ cases had infectious uveitis. Overall, intraocular tuberculosis (IOTB), herpetic and syphilitic uveitis were the commonest infectious causes. Sarcoidosis and HLA-B27-associated uveitis were the commonest non-infectious causes. In anterior uveitis, HIV+ cases most frequently had probable IOTB, syphilitic or idiopathic uveitis while HIV- cases had possible IOTB, idiopathic or HLA-B27-associated uveitis. In panuveitis, HIV+ cases mostly had syphilis, probable IOTB, toxoplasma and varicella-zoster virus whereas HIV- cases mostly had possible IOTB, sarcoidosis and idiopathic uveitis.

CONCLUSION

Infectious uveitis is common in South Africa, especially amongst HIV+ patients. Causes of anterior and panuveitis differ between HIV+ and HIV- patients.

Patterns of Uveitis at Two University-Based Referral Centres in Cape Town, South Africa

Purpose: To analyze the pattern of uveitis at two tertiary hospitals in South Africa which has a high prevalence of HIV, TB and syphilis. Methods: Data of 198 patients were obtained retrospectively between August 2014 and August 2016, including patient demographics, clinical examination, special investigations and final diagnosis. Results: Infectious uveitis was the most common aetiological category (47%), followed by idiopathic (34.8%) and non-infectious (18.2%). Syphilis was the most common identifiable cause (16.2%). Other important causes were toxoplasmosis, herpes viruses, tuberculosis and HLA-B27. HIV positive patients, who constituted 40% of the study population, were more likely to present with a posterior or panuveitis (relative risk 1.50, 95% CI 1.19-1.89) and more likely to have an infectious cause compared to HIV negative patients (relative risk 2.47, 95% CI 1.82-3.35). Conclusions: This study emphasizes the importance of HIV testing and investigations for infectious causes of uveitis, especially syphilis, in this population.

Uveitis is predominantly of infectious origin in a high HIV and TB prevalence setting in rural South Africa

AIMS

To determine the burden of disease in a unique sample of patients with uveitis from a rural South African setting.

METHODS

Data in this cross-sectional study were collected from patients presenting with uveitis (n=103) at the ophthalmology outpatient department of three hospitals in rural South Africa. Demographic and clinical data were collected, and laboratory analysis of aqueous humour, serological evaluation and routine diagnostics for tuberculosis (TB) were performed.

RESULTS

Sixty-six (64%) participants were HIV infected. Uveitis was predominantly of infectious origin (72%) followed by idiopathic (16%) and autoimmune (12%). Infectious uveitis was attributed to herpes virus (51%), Mycobacterium tuberculosis (24%) and Treponema pallidum (7%) infection. HIV-infected individuals were more likely to have infectious aetiology of uveitis compared with HIV-uninfected individuals (83% vs 51%; p=0.001).

CONCLUSIONS

Microbial aetiology of uveitis is common in areas where HIV and TB are endemic. In these settings, a high index of suspicion for infectious origin of uveitis is warranted.

What you can see in your patient's eyes? Review of ocular manifestations of HIV in HAART era

The early diagnosis and treatment of ocular disease to prevent morbidity and mortality of patients with human immunodeficiency virus (HIV) is of paramount importance. Since the advent of highly active antiretroviral therapy (HAART), the incidence of ocular complications of HIV has decreased and their manifestations and natural course are also modified. This has been observed in the face of emerging immune recovery, which per se has brought new difficulties in the process of diagnosing and management of the ocular disease. Conditions such as immune recovery uveitis could affect eyes with history of opportunistic disease with a potential to cause vision loss; with this regard, differentiation of the inflammatory process from infective causes is essential. The other sexually contracted diseases are also to be included in this complex picture because of their contribution to the clinical picture and also sharing common routes of transmission with HIV. There is very little doubt that visual deterioration would further deteriorate the already compromised quality of life of this group of patients. In this review, authors wish to provide evidence available in the medical literature around the visual health issues in HIV-infected patients and raise awareness towards the changing pattern of the ocular disease in the HAART era.

Rifabutin-induced hypopyon uveitis in patients with acquired immunodeficiency syndrome infected with Mycobacterium avium complex

Rifabutin is a semi-synthetic antimycobacterial agent mainly used in the prophylaxis and treatment of Mycobacterium avium complex (MAC) in acquired immunodeficiency syndrome patients. Uveitis as a side effect of rifabutin has been recognized and established since 1994, but there was no case previously described in Taiwan so far. We report 2 cases of rifabutin-induced hypopyon uveitis in patients with human immunodeficiency virus and MAC infection. Both patients received the regimen of clarithromycin and rifabutin to treat MAC infection. Uveitis resolved after discontinuing of rifabutin and treatment with topical corticosteroid and mydriatics. Early recognition of this entity can prevent invasive ocular procedures and treatments. Doctors who prescribe rifabutin should be aware of this ocular complication of uveitis and drug-drug interactions. Ophthalmologists should put this on the list of differential diagnoses for uveitis.

Ocular association of HIV infection in the era of highly active antiretroviral therapy and the global perspective

Ocular involvement is a common complication of HIV infection. Since the late 1990s, widespread use of highly active antiretroviral therapy (HAART) has altered the spectrum, and reduced the incidence of ocular involvement in developed countries. The incidence of the most common ocular opportunistic infection, cytomegalovirus retinitis, has decreased tremendously. However, immune recovery uveitis secondary to HAART has emerged as a frequent visually threatening condition. Early diagnosis and treatment with periocular steroids is helpful in minimizing visual loss. Clinicians should also be aware that certain antimicrobial agents used to treat opportunistic infections in HIV-positive patients are associated with potentially serious ocular side effects. In developing countries, where most of the world's 40 million HIV-positive patients live, the spectrum and incidence of ocular involvement differ from those in developed countries. The lack of HAART availability is among the many causes of these differences, which may include nutritional factors, basic medical care availability and the levels of exposure to different infectious agents. These factors add to the already challenging task of treating ocular complications and preventing blindness in HIV-positive patients in developing countries.