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).