Case report:
A 25-year-old woman came to the emergency department of Khatam-Al-Anbia eye hospital (affiliated with Mashhad University of Medical Sciences, Mashhad, Iran) with complaints of acute decreased vision, photophobia, and redness in the right eye from one week ago. She had no history of trauma or eye surgery. The patient had a history of mild fever with right shoulder pain 4 months ago. She did not have a history of night sweats or coughing.
Because of the endemic area where she lived, the physician suspected brucellosis. The wright test and 2-mercaptoethanol test were 1/80 and 1/40 respectively which was positive for the patient. ESR (erythrocyte sedimentation test) was 38 and CRP (C-Reactive Protein) 1+ in the labs’ test. Accordingly, she was treated with oral doxycycline and trimethoprim-sulfamethoxazole. The patient had poor compliance with medicine consumption. During these 4 months, the patient experienced some sort of pain in her shoulders and a mild fever with an on-off pattern.
The best-corrected visual acuity with a tumbling E-chart in the right eye at the time of presentation was hand motion with projection and 10/10 in the left eye. Intraocular pressure (IOP) was within the normal limit in both eyes. The anterior segment examination of the right eye showed clear cornea, hypopyon and flare, and 4+ vitreous cells (based on SUN Working Group) 4. We found no iris nodules and posterior synechia. Fundus examination of the right eye revealed optic disc swelling, diffuse vasculitis, and a retinitis patch located one disc diameter below the optic nerve head. The left eye was entirely normal.
With the possible diagnosis of vision-threatening endogenous endophthalmitis or infectious retinitis, the patient was admitted for further diagnostic evaluations and therapies. Regarding the positive history of Wright test and symptoms of brucellosis, consultation with an infectious diseases specialist for more systemic evaluations was performed. Systemic work-ups and laboratory tests including blood, urine, throat culture, chest x-ray, complete blood count, platelet count, blood urea nitrogen, creatinine, urine analysis, and cardiologic consult for the possibility of infectious endocarditis were unremarkable. However, the Wright test was still positive.
Vitreous sampling was performed with a 25-gauge needle through pars plana and evaluated for polymerase chain reaction (PCR) to detect the Herpes Simplex virus, Varicella Zoster virus, Cytomegalovirus, Brucella, and smear and culture. Intravitreal vancomycin (1 mg/0.1 ml), and ceftazidime (2.25 mg/0.1 ml) were injected. Regarding the suspicion of herpetic retinitis, we started valacyclovir, 1000mg tablets every 8 hours for the patient.
The PCR test was positive only for B. melitensis. The previous systemic medications for brucellosis were continued and oral prednisolone 50 mg/day was prescribed. Due to severe vitreous inflammation, a three-port 23-gauge pars plana vitrectomy with silicone oil tamponade was performed on the third day of admission. After the removal of all vitreous inflammatory debris and membranes, we found diffuse retinal vasculitis and multiple retinitis patches around the optic disc.
Two months later, because of significant cataracts and near-total rhegmatogenous retinal detachment (RRD) and subretinal fibrotic bands under silicon oil, we performed cataract surgery with intraocular lens implantation, silicone oil removal, 23G-re-vitrectomy, and subretinal band removal and re-injection of silicone oil (5700 centistoke viscosity). Systemic antibiotics were prescribed for six weeks, the systemic corticosteroid was tapered off for the patient, and brucellosis treatment was completed.
At the final follow-up, the visual acuity of the right eye was hand motion with projection. IOP was 4 mmHg. A retinal fold was developed, and the right eye was pre-phthisis bulbi condition.
The left eye was completely normal at the last visit (figure 1).