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06-17-2012, 11:37 AM
TB Uveitis

48 year-old African American female with complaint of photophobia, tearing, and eye pain in both eyes

Andrew Doan, MD, PhD, Ayad Farjo, MD
February 21, 2005
Chief Complaint: 48 year-old African American female with complaint of photophobia, tearing, and eye pain in both eyes.
History of Present Illness: 48 year-old AA HIV(+) female with 1 month of gradual photophobia, tearing, and eye pain in both eyes. She was started on anti-retroviral therapy (ART) 1 year ago when her CD4 count was <50. After starting ART, her CD4 count has been above 250. She was doing well until one month ago when she complained of increasing redness and eye pain in both eyes. On presentation, she was photophobic.
No complaint of fevers, chills, or night sweats. No joint pains. No shortness of breath. No other complaints. No recent exposures to illnesses.
PMH: HIV(+) on antiretroviral therapy. TB test performed one year previous was negative, but the candida control was also negative. No previous ocular problems.
Exam:

Best corrected visual acuities: 20/50 OD and 20/40 OS.
Pupils: irregularly shaped (see photo), reactive, no RAPD.
IOP: normal
EOM: full OU
VF: normal
DFE: retina exam notable for normal macula, vessels, and periphery OU. No vitreous cells.
SLE: notable for marked conjunctival injection OU, ciliary flush OU, 2+ cell/flare OU, and large keratic precipitates (KP) on the corneal endothelium OU. There was central posterior synechia around the pupil margin OU.
SLE Photo of the right eye (left eye similar)
http://webeye.ophth.uiowa.edu/eyeforum/cases-i/cases/redeye_03042004.jpg
SLE Photo of the right eye denoting some "mutton fat" KP (higher magnification)
http://webeye.ophth.uiowa.edu/eyeforum/cases-i/cases/redeye2_03042004.jpg
Discussion

Tuberculosis Uveitis

This is a patient with HIV and an anergic TB skin test one year previous when her CD4 count was low. After starting ART, she was doing well until her granulomatous (mutton fat) uveitis developed. We know this process was long standing because of the central posterior synechiae (pupil being tacked down to the anterior lens capsule by inflammation). We repeated a TB skin test, and it was POSITIVE because now she had a reconstituted immune system to mount a skin response. We also worked her up for syphilis and sarcoid, which were negative. In an HIV patient, the uveitis can be a result of immune reconstitution syndrome (patients are usually much more ill) or from the original HIV infection. The latter is a diagnosis of exclusion.
We referred this patient to internal medicine/infectious disease for treatment. We started her on prednisolone drops (steroid for inflammation) and homatropine or scopolamine (dilation and cycloplegic to prevent further synechial formation and for comfort- it's best to use an intermediate cycloplegic so the pupil can react to prevent peripheral anterior synechiae formation).
Diagnosis: Granulomatous Uveitis

EPIDEMIOLOGY


Variable due to numerous etiologies
SIGNS


mutton fat KP
anterior segment cell and flare
conjunctival/episcleral injection
may be associated with an anterior vitritis from spill over
synechiae formation
Koeppe nodules (cluster of cells on pupil margin)
Busacca nodules (cluster of cells on iris)
SYMPTOMS


Photophobia
Tearing
Decreased vision
Pain
TREATMENT


cycloplegic, scopolamine 0.25% BID
prednisolone acetate 1% every 1-4 hours
treat secondary glaucoma
treat underlying disorder
periocular injection of steroids may be needed for severe cases not responding to topical managment.

Differential Diagnoses:


Sarcoidosis
Syphilis
Vogt-Koyanagi-Harada syndrome (associated with posterior retinal findings, poliosis, vitiligo, and sometimes hypopyon)
Sympathetic ophthalmia
Multiple sclerosis
Lyme disease
Tuberculosis
Herpes zoster
Coccidioidomycosis
Leprosy
Toxoplasmosis (usually associated with a posterior uveitis)
Brucellosis
Idiopathic (includes immune reconstitution syndrome and HIV uveitis)