Diagnostic Challenges in PD-1 Inhibitor Induced Panuveitis in a Teenage Girl with Chest Soft Tissue Sarcoma - A Case Report

PURPOSE

To report a case of programmed cell death receptor-1 (PD-1) inhibitor induced panuveitis.

METHOD

Observational case report of a 13-year-old Chinese girl presented as panuveitis. The clinical course, imaging performance, laboratory examination, differential diagnosis, treatment and prognosis were described.

RESULT

Patient presented with bilateral anterior granulomatous uveitis, vitritis, papillitis, and various creamy yellow nodular lesions in the mid-peripheral fundus. She had a history of biopsy proven alveolar soft tissue sarcoma on the chest wall and pulmonary metastasis, and a PD-1 inhibitor (sintilimab) was intravenously administered. Blood tests, magnetic resonance imaging of the cranium and the orbit, aqueous humor assay of inflammatory cytokines and microbial DNA were performed to distinguish infectious and non-infectious uveitis, choroidal metastases, and intravenous injection-related endophthalmitis. The oncologist evaluated that the sarcoma was stable and terminated sintilimab dosage. After sintilimab withdrawal, the blurred vision improved. Then, the patient received oral corticosteroids, resulted in resolution of the panuveitis. A diagnosis of PD-1 inhibitor induced panuveitis was made.

CONCLUSION

For patients taking PD-1 inhibitors, the major diagnostic challenge is to identify whether the cause of the uveitis is due to the antitumor treatment or not. It is suggested to be screened by eye care specialist and timely referral to uveitis specialist with any suspicion of intraocular inflammation for these patients.

SYPHILITIC OUTER RETINOPATHY: A MASQUERADING DIAGNOSIS REVEALED AFTER STEROID-INDUCED PROGRESSION TO PANUVEITIS

PURPOSE

To report a case of syphilitic outer retinopathy revealed after progression to panuveitis after a course of oral steroids for suspected poison ivy.

METHODS

Retrospective case report.

RESULTS

A 44-year-old diabetic man presented with progressive symptoms of nyctalopia and color vision changes associated with outer retinal disruption on macular imaging but minimal evidence of intraocular inflammation on examination. A short course of oral steroids for an unrelated skin condition induced rapid progression to frank panuveitis with retinal vascular sheathing and retinal whitening. Systemic workup identified syphilis as the etiology. The patient's visual symptoms and disruption of the photoreceptor and retinal pigment epithelial layers on OCT improved after treatment with IV penicillin.

CONCLUSION

Syphilitic outer retinopathy represents an unusual manifestation of ocular syphilis that can present with minimal examination findings. We present here a case of oral steroid use resulting in the progression of syphilitic outer retinopathy to a more fulminant form of syphilitic uveitis that ultimately revealed the correct diagnosis and prompted the correct intervention. This case highlights the importance of maintaining a high level of suspicion for this treatable condition.

Panuveitis Presumed Secondary to Ibrutinib Therapy

Although a small number of cases of secondary uveitis have been documented in the setting of ibrutinib therapy, panuveitis has not previously been described with this medication. The authors describe a presumed case of panuveitis in a patient on ibrutinib for chronic lymphocytic leukemia. The purpose of this report is to document a case of asymmetric, bilateral panuveitis in the setting of ibrutinib use. Panuveitis may develop in the setting of ibrutinib use, and local steroid therapy can be successfully used for treatment without cessation of systemic cancer therapy. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:160-164.].

OCULAR TOXICITY AFTER INADVERTENT INTRACAMERAL INJECTION OF HIGH DOSE OF CEFUROXIME DURING CATARACT SURGERY: A CASE SERIES

PURPOSE

To report ocular side effects after inadvertent intracameral injection of a high dose of cefuroxime.

METHODS

Nineteen eyes of 19 patients were seen in our eye department 1 week after the referring surgeon had injected an erroneous dose of intracameral cefuroxime (12.5 mg/0.1 mL in 14 patients, Group A, and 10 mg/0.1 mL in 5 patients, Group B) at the end of a cataract surgery. A complete ophthalmic examination was performed postoperatively.

RESULTS

Eight patients (42.10%) exhibited ocular side effects. One patient (Group A) developed a noninfectious panuveitis. One case (Group B) had a serous macular detachment. Five patients (4 from Group A and 1 from Group B) showed a disruption of the ellipsoid layer with temporary/permanent drop in visual acuity. One patient presented with color alteration (Group A), but electrodiagnostic studies did not reveal any significant alterations.

CONCLUSION

Anterior and posterior inflammation has been described after intracameral injection of high dose of cefuroxime. In this study, 10 mg to 12.5 mg of intracameral cefuroxime is shown to be, principally, toxic to the retina with transient or permanent retinal changes on optical coherence tomography which correlate with visual outcomes postoperatively. Protocols to avoid dilution errors should be available in theaters during cataract surgery where such commercial preparations are not available.

Recurrent grade 4 panuveitis with serous retinal detachment related to nivolumab treatment in a patient with metastatic renal cell carcinoma

Blockade of programmed cell death-1 (PD-1) has become one of the most promising immunotherapies for many human cancers. However, immune-related adverse events can be produced by anti-PD-1 therapy. Uveitis is a rare but potentially devastating side effect of anti-PD-1 therapy. Delay in diagnosis or improper treatment may eventually lead to irreversible blindness. Therefore, it is important for the oncologist and the ophthalmologist to recognize and manage this adverse event properly in patients receiving anti-PD-1 therapy in a timely manner. Here we present a grade 4 panuveitis with bilateral serous retinal detachment following treatment with nivolumab for metastatic renal cell carcinoma. Oral prednisone, topical steroid eye drops, periorbital injection of steroid and finally intravitreal injection of steroid implant were administered in our patient. We observed that intravitreal injection of dexamethasone implant, but not the periorbital injection of steroid or the steroid eye drops, was effective to control the posterior uveitis and serous retinal detachment. Oral prednisone was also effective, but it might affect the efficacy of anti-PD-1 therapy and promote tumor growth. We also summarize 15 cases of uveitis reported to date related to nivolumab or pembrolizumab therapy in the present study. The symptoms, signs, potential underlying mechanisms and treatment options regarding this adverse event are discussed.

Uveitis and serous retinal detachment secondary to systemic dabrafenib and trametinib

CASE REPORT

The case is presented of a 39-year-old woman with metastatic melanoma treated with dabrafenib and trametinib. She presented with a severe acute panuveitis with granulomatous anterior uveitis, vitritis, and multiple serous retinal detachments. Dabrafenib and trametinib were suspended, and treatment with a systemic and topical corticosteroid was started. A good response was obtained, with a recovery of visual acuity of 1.0 in both eyes within two weeks.

DISCUSSION

Dabrafenib and trametinib can lead to severe uveitis. Treatment with corticosteroids and discontinuation of therapy with dabrafenib and trametinib led to an anatomical and functional improvement, and resolved the episode rapidly. Ophthalmologists must be aware of this toxicity, given the increasing use of those drugs.

Bilateral panuveitis in a patient on vemurafenib BRAF inhibitor therapy for stage IV melanoma

PURPOSE

To describe a case of recurrent, bilateral panuveitis caused by the BRAF proto-oncogene inhibitor vemurafenib.

METHODS

Case report.

RESULTS

A 25-year-old woman developed bilateral panuveitis and macular edema after initiating treatment with the BRAF enzyme inhibitor vemurafenib for stage IV cutaneous melanoma. The patient was successfully treated with sub-Tenon triamcinolone injections along with cessation of the medication.

CONCLUSIONS

Panuveitis is a potential adverse effect of vemurafenib. Good communication with oncology is necessary, in case the medication needs to be discontinued.

[Unilateral panuveitis following intravesical therapy with bacille of Calmette et Guerin]

Uveitis occuring after Mycobacterium bovis-bacille Calmette-Guerin (BCG) intravesical therapy for bladder carcinoma is rare. Only a few cases have been described. Its physiopathology is still unknown. Two mechanisms can be proposed at the origin of ocular inflammation: a local immune response or a direct choroidal mycobacterial infection as demonstrated by vitreous cultures. We report the case of 63-year-old man who presented with unilateral panuveitis after the fifth BCG intravesical instillation with no other systemic manifestations. There was no evidence for any other etiology for this uveitis. Loss of light perception occurred despite systemic antimycobacterial therapy and systemic prednisone therapy because of delayed diagnosis. This outlines the absolute need for a close ophthalmological monitoring of patients receiving a BCG therapy to allow an earlier diagnosis of this complication and appropriate treatment.

Rifabutin-Associated Panuveitis with Retinal Vasculitis in Pulmonary Tuberculosis

INTRODUCTION

Rifabutin-associated uveitis has been reported frequently in AIDS patients and more rarely in immunocompetent patients. It is characterized clinically by anterior acute uveitis. Only a few poorly documented cases of rifabutin-induced panuveitis with retinal vasculitis have been reported. Here, we report four cases of rifabutin-associated panuveitis with retinal vasculitis.

CASE REPORTS

We describe four patients with active tuberculosis, treated with a multidrug regimen including rifabutin for at least 1.5 months before presentation. The first patient was immunocompetent, the three others had AIDS and were undergoing triple anti-HIV therapy. Three patients were women with a low body weight. All four patients presented with panuveitis and retinal vasculitis. Interruption of the drug rapidly reduced the ocular inflammation in all cases.

CONCLUSION

Four cases of rifabutin-associated panuveitis with retinal vasculitis are reported in patients with active pulmonary tuberculosis. Immunogenicity of Mycobacterium tuberculosis as well as the very low weight of the patients might be implicated in the development of this unusual form of rifabutin-associated uveitis.

[Panuveitis following intravesical bacille Calmette-Guerin therapy]

Uveitis occurring after bacille Calmette-Guerin (BCG) intravesical therapy for bladder carcinoma is rare: only nine cases have been described. In two previous reports, vitreous cultures proved Mycobacterium bovis presence. We describe the case of an 85-year-old woman who presented with bilateral panuveitis 2 months after the last BCG intravesical instillation, with no other systemic symptom. There was no evidence for any other etiology for this uveitis. She was given oral antibiotics that were effective against Mycobacterium species, oral steroids, and anti-inflammatory drops. Her ophthalmologic status dramatically improved. This case highlights that these patients may have a good visual outcome, as long as diagnosis and treatment are not delayed.

[Biphosphonates and intraocular inflammation]

PURPOSE/MATERIAL AND METHOD: A 67 year old woman had been taking oral alendronate in a single weekly dose of 70 mg. She developed panuveitis in her right eye and anterior uveitis in the left. The uveitis was resolved with steroids and discontinuation of alendronate. Three weeks later alendronate was reinstituted and this produced a recurrence. Her past medical history revealed that she had a temporal arteritis but her past ocular history was unremarkable.

RESULTS/CONCLUSION

Disodium alendronate can cause intraocular inflammation (panuveitis and anterior uveitis), which requires discontinuing the treatment.

Immune recovery vitritis presenting as panuveitis following therapy with protease inhibitors

Immune reconstitution in acquired immunodeficiency syndrome (AIDS) patients on highly active anti-retroviral therapy (HAART) with cytomegalovirus (CMV) retinitis manifested as posterior segment intraocular inflammation has been reported. We report an adult HIV-positive Indian male with clinically inactive CMV retinitis who developed panuveitis with hypopyon. This was related to immune recovery mediated by combination anti-retroviral treatment, including protease inhibitors.

Intravitreal sustained-release cyclosporine in the treatment of experimental uveitis

OBJECTIVE

Uveitis often is a chronic disease requiring long-term medical therapy. Despite treatment, the disease may be difficult to control and may produce serious, vision-threatening ocular complications. In this study, the authors determined whether an intravitreal cyclosporine-sustained delivery device was effective in the treatment of ocular inflammation in a rabbit model of uveitis.

METHODS

New Zealand White rabbits were immunized subcutaneously with Mycobacterium tuberculosis H37Ra antigen. Fourteen days later, sustained-release cyclosporine devices were implanted into the vitreous cavity of the right eye of experimental rabbits. Control animals received sham devices. Seven days after device implantation, rabbits were challenged with an intravitreal injection of tuberculin antigen. To simulate chronic inflammation with exacerbations, some animals were rechallenged with intravitreal antigen on day 21 after device implantation. Inflammation was assessed clinically by a masked observer who graded anterior chamber cells, flare, corneal neovascularization, iris congestion, and vitreous opacity daily until day 7 and on day 13 after the initial intravitreous challenge, and on days 1 and 2 after the rechallenge. Retinal function was evaluated by electroretinography. Animals were killed 3, 6, 8, and 14 days after the initial intravitreal challenge and on the second day after rechallenge for aqueous leukocyte count, protein measurement, and histologic examination. The number of aqueous and peripheral blood proliferating lymphocytes and the subset of CD4+ T cells were determined by flow cytometry. High-performance liquid chromatography was used to measure cyclosporine A levels in vitreous and peripheral blood. Light microscopy was used to evaluate the eyes histopathologically.

RESULTS

By clinical criteria, treated eyes had significantly less inflammation than untreated eyes. The number of aqueous cells and protein concentration determined quantitatively paralleled the clinical assessment of anterior chamber cells and flare. The electroretinography B-wave was depressed significantly in untreated eyes compared with that of treated eyes (P < 0.02). Histopathologic examination results showed marked inflammation and tissue disorganization in untreated eyes, whereas cyclosporine-treated eyes had preserved architecture and greatly reduced inflammatory cells. Intravitreal cyclosporine remained at therapeutic levels for at least 6 months after intravitreal device implantation, whereas blood levels were low to nondetectable.

CONCLUSIONS

The intravitreal cyclosporine A device effectively suppresses ocular inflammation in a rabbit model of uveitis. This device may be useful in the treatment of patients with severe chronic uveitis who are intolerant to currently available therapies.

Experimental autoimmune uveoretinitis induced by the gamma-subunit of cyclic guanosine monophosphate phosphodiesterase in rats

PURPOSE

To investigate the capacity of the recombinant gamma-subunit (P gamma) of cyclic guanosine monophosphate phosphodiesterase to induce experimental autoimmune uveoretinitis in Lewis rats.

METHODS

Bovine P gamma was expressed in Escherichia coli cells and purified by fast protein liquid chromatography. Lewis rats were immunized by a single footpad injection of P gamma emulsified in complete Freund's adjuvant. Clinical and histopathologic changes in the eye and pineal gland were examined. Lymphocytes were prepared from the lymph nodes of rats with uveitis and transferred by intraperitoneal injection to naive recipient rats.

RESULTS

Immunization of rats with P gamma induced panuveitis and pinealitis with clinical and histopathologic changes similar to those induced by S-antigen. Lymphocytes from the lymph nodes of diseased rats transferred uveitis to naive recipients.

CONCLUSIONS

P gamma, a retina-specific protein of molecular weight less than 10,000 kDa, is capable of inducing uveoretinitis in Lewis rats. The disease can be transferred adoptively to naive rats by injection of lymphocytes from donor rats with experimental autoimmune uveoretinitis. Inflammation of the pineal gland of immunized rats suggests that P gamma is not only localized to the retina but also to the pineal gland.

Antifibrotic and uveitogenic properties of gamma interferon in the rabbit eye

The feasibility of gamma (gamma)-interferon injection for the treatment of ocular fibrotic conditions was studied in rabbits using recombinant rabbit gamma-interferon and the cell-injection model of tractional detachment. A toxicity study revealed that intravitreal injection of greater than 10(4) units gamma-interferon consistently produced panuveitis. For tractional detachment, 250,000 rabbit dermal fibroblasts were injected intravitreally into 20 eyes; 1 day later, 5 of these eyes received intravitreal injections of 10(4) units gamma-interferon, another 5 were given 10(6) units, and the remaining 10 received balanced salt solution. Slit-lamp examination and fundus photography were performed at regular intervals for 21 days and were graded by a masked observer. The eyes were then enucleated and processed for histology. Doses of 10(4) units gamma-interferon significantly reduced the severity of detachments, but injections of 10(6) units induced panuveitis.