RESUMO
INTRODUCTION: Ocular tuberculosis (TB) diagnosisremains difficult and quantiferon (QFT) contribution needs still yet to be specified, despite its generalization in France. The purpose of this observational study is to assess in which ocular inflammation (OI) presentation QFT is prescribed and to evaluate the added value of new QuantiFERON®-TB Gold Plus (QFT-Plus) test for diagnosis ocular TB diagnosis. PATIENTS AND METHODS: Monocentric, observational study, carried out in an ophthalmology department over a period of 5 months. Inclusion criteria were defined as an existence of an OI for which a QFT-Plus test was part of the etiological investigations. Of the 316 consecutive files, 72 were excluded (indeterminate test, prescription before anti-TNFα or immunosuppressant initiation, missing data, wrong indication) and 244 were selected and divided into two groups: group one (anterior uveitis/episcleritis, n=129) and group two (intermediate/posterior uveitis/optic neuritis/ocular myositis, n=115). All positive QFT patients underwent an etiological investigation including thoracic imaging. RESULTS: Forty-five patients, aged 52±12 years, had positive QFT (18.5%), including 18 patients for group 1 and 27 for group 2. Living in TB-endemic area, TB exposure and chest imaging abnormalities were identified in 70%, 27% and 22% of cases, respectively. OI was chronic in 36% of cases (group one, 4/18; group two, 12/27). None of the 18 patients, in group 1, received anti-tuberculosis treatment (ATT) or experienced a relapse during one-year follow-up. Four QFT+ patients, from group 2 (15%) had another associated disease explaining their uveitis. Among the 23 other patients without identified etiology, 13 had at least one relevant ophthalmological signs predictive of TB uveitis (posterior synechiae, retinal vasculitis and/or choroidal granuloma) (59%). Eleven patients received a 6-month ATT trial. Radiological abnormalities and granulomas at angiography were significantly more frequent among treated patients (p=0.03 and 0.001, respectively). A full OI recovery was observed for 8 patients (73%), considered ex-post as ocular TB. Nine patients in group 2 received rifampicin/isoniazid dual therapy for 3 months, but no conclusion could be drawn as to the benefit of such prescription on OI. QFT rate comparison, according to CD4 stimulation by ESAT-6/CFP-10 peptides or by CD4/CD8 co-stimulation, was comparable and found only 4 cases of discrepancy (1.6%). None of these 4 cases had ocular TB diagnosis. CONCLUSION: Positive QFT frequency among patients consulting for posterior OI remains high. In this study, radiological abnormalities and granulomas at angiography seemed to be more closely related to clinician decision for starting ATT trial in QFT+ patients, which was effective in 73% of cases. QFT-Plus does not seem more relevant than QFT-TB in exploring an OI. Prospective studies are necessary to codify QFT management in the etiological assessment of OI and clearly define ATT trial indications as well as their modalities.
Assuntos
Esclerite , Tuberculose Ocular , Uveíte , Adulto , Humanos , Testes de Liberação de Interferon-gama , Pessoa de Meia-Idade , Estudos Prospectivos , Teste Tuberculínico , Tuberculose Ocular/diagnóstico , Tuberculose Ocular/tratamento farmacológico , Tuberculose Ocular/epidemiologia , Uveíte/diagnóstico , Uveíte/tratamento farmacológico , Uveíte/epidemiologiaRESUMO
Conventional immunosuppressive drugs, anti-TNF alpha and other biotherapies used in clinical practice are capable of controlling non-infectious anterior uveitis, posterior uveitis and panuveitis. The present work has been led by a multidisciplinary panel of experts, internists, rheumatologists and ophthalmologists and is based on a review of the literature. In case of corticodependency or sight-threatening disease, conventional immunosuppressive drugs (methotrexate, azathioprine and mycophenolate mofetil) and/or anti-TNF alpha (adalimumab, infliximab) are used to achieve and maintain remission. Interferon is an efficient immunomodulatory treatment, as a second-line therapy, for some therapeutic indications (refractory macular edema, Behçet's vascularitis). Other biologics, especially tocilizumab, are showing promising results. Local treatments (corticosteroids, sirolimus etc.) are adjuvant therapies in case of unilateral inflammatory relapse. Therapeutic response must be evaluated precisely by clinical examination and repeated complementary investigations (laser flare photometry, multimodal imaging, perimetry, electroretinography measures).
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Guias de Prática Clínica como Assunto , Uveíte/terapia , Corticosteroides/uso terapêutico , Anticorpos Monoclonais/uso terapêutico , Produtos Biológicos/uso terapêutico , Terapia Biológica/métodos , Prova Pericial , Humanos , Imunossupressores/uso terapêutico , Guias de Prática Clínica como Assunto/normas , Fator de Necrose Tumoral alfa/imunologiaRESUMO
Scleritis is an inflammatory disease of the sclera; outer tunic of the eye on which the oculomotor muscles are inserted. It can be associated with a systemic disease up to one time out of 3. These associated diseases are mainly rheumatoid arthritis, vasculitis, including granulomatosis with polyangiitis in the first line and spondyloarthropathies. Before mentioning such an etiology, it is necessary to eliminate an infectious cause, mainly herpetic, which is regularly underestimated. The classification of scleritis is clinical. We distinguish between anterior scleritis and posterior scleritis. Anterior scleritis is diffuse or nodular, usually of good prognosis. Anterior necrotizing scleritis with inflammation is often associated with an autoimmune disease, necrotizing scleritis without inflammation usually reflects advanced rheumatoid arthritis. The treatment of these conditions requires close collaboration between internists and ophthalmologists to decide on the use of corticosteroid therapy with or without immunosuppressors or biotherapies.
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Doenças Autoimunes , Conhecimentos, Atitudes e Prática em Saúde , Inflamação , Medicina Interna/métodos , Médicos , Esclerite , Doenças Autoimunes/complicações , Doenças Autoimunes/diagnóstico , Doenças Autoimunes/terapia , Técnicas de Diagnóstico Oftalmológico , Humanos , Inflamação/complicações , Inflamação/diagnóstico , Inflamação/terapia , Esclerite/diagnóstico , Esclerite/etiologia , Vasculite/complicações , Vasculite/diagnóstico , Vasculite/terapiaRESUMO
Ocular drug side effects are very varied and can affect all the structures of the eye. The purpose of this review is to help clinicians: (i) to evoke this drug-induced toxicity yearly in the course of an unexplained ocular injury, before its damage become irreversible, (ii) to be able to recognize induced paradoxical ocular inflammation, mimicking an inflammatory pathology flare-up, especially in patient under anti-TNF regimen and (iii) to propose a more in-depth knowledge on recently described ocular toxicities from targeted cancer therapy, mainly the tyrosine kinase inhibitors.
Assuntos
Técnicas de Diagnóstico Oftalmológico , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/diagnóstico , Uveíte/induzido quimicamente , Uveíte/diagnóstico , Diagnóstico Diferencial , Técnicas de Diagnóstico Oftalmológico/normas , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/complicações , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/terapia , Humanos , Doença Iatrogênica , Oftalmologia/métodos , Uveíte/epidemiologia , Uveíte/terapiaRESUMO
Inflammatory orbitopathies relate to an inflammatory state originating within the orbit and its adnexes, except the inner ocular globe. Orbital inflammation (OI) may be either localized manifestation of a proven or like autoimmune disease, or local response from immune system against infectious, structural or tumoral antigens. We review the clinical manifestations of OI, which provide helpful clues to the diagnosis and describe the inflammatory, infectious and neoplastic conditions classically associated with OI. Autoimmune diseases are probably the most common causes of OI associated with a bilateral dacryoadenitis (e.g., sarcoidosis, granulomatosis with polyangiitis, IgG4-related disease). We focused on a major part of the IgG4-RD spectrum, the IgG4-related orbital disease which has been recently described and the idiopathic orbital inflammation syndrome that one should consider in patients 40 years of age or older with non specific inflammation OI on biopsy but without underlying local or systemic disease. An algorithm for the diagnostic approach of OI was proposed. If systemic explorations fail to diagnose an underlying disease, histopathologic control is required for distinguishing non-specific OI from other differential diagnosis, especially lymphoma. In the cases of pure myositic locations and posteriorly located tumours where biopsy could damage to the optic nerve, analysis of orbital lesions in T2W IRM sequence may be helpful to distinguish idiopathic OI (IOI) from lymphoma. When the diagnostic work-up fails, a corticosteroid trial could be used, but its beneficial effect has to be cautiously interpretated before definitively diagnosing IOI. Finally, treatments used in main infllammatory orbitopathies were also reviewed.
Assuntos
Técnicas de Diagnóstico Oftalmológico , Conhecimentos, Atitudes e Prática em Saúde , Inflamação/diagnóstico , Medicina Interna/métodos , Doenças Orbitárias/diagnóstico , Médicos , Algoritmos , Diagnóstico Diferencial , Humanos , Inflamação/complicações , Inflamação/etiologia , Inflamação/terapia , Doenças Orbitárias/complicações , Doenças Orbitárias/etiologia , Doenças Orbitárias/terapiaRESUMO
INTRODUCTION: Diagnostic work-up of uveitis involves many uncertainties. Search for an etiology should take into account the epidemiology of uveitis and focus on the most severe diseases or those, which can be treated. This work was undertaken to establish recommendations for the diagnosis work-up of uveitis. METHODS: Recommendations were developed by a multidisciplinary panel of 15 experts, including internists, ophthalmologists and a rheumatologist and are based on a review of the literature with regard to effectiveness of investigations and the results of the ULISSE study, which is the first prospective study assessing the efficiency of a standardized strategy for the etiological diagnosis of uveitis. Children, immunocompromised patients, severe retinal vasculitis and specific ophthalmological entities are excluded from these recommendations. RESULTS: Investigations should be first guided by the history and physical examination. Serological screening for syphilis is the only test appropriate in all forms of uveitis. If no diagnosis is made after this stage, we propose investigations guided by the anatomic characteristics of uveitis. It includes HLA B27 testing (in unilateral acute anterior non-granulomatous uveitis), serum angiotensin converting enzyme, interferon-gamma release assay and chest CT (chronic uveitis), cerebral MRI and anterior chamber tap with IL10 analysis (intermediate or posterior uveitis in patients over 40 years). Investigations ordered in the absence of orientation are almost always unhelpful. CONCLUSIONS: We propose a strategy for the etiologic diagnosis of uveitis. The recommendations should be updated regularly. The efficiency of more invasive investigations has yet to be evaluated.
Assuntos
Técnicas de Diagnóstico Oftalmológico/normas , Guias de Prática Clínica como Assunto , Uveíte/diagnóstico , Adulto , Criança , Prova Pericial , Humanos , Programas de RastreamentoRESUMO
INTRODUCTION: Lymphogranuloma venereum (LG) is a sexually transmitted infection (STI) caused by Chlamydia trachomatis L serovar. METHODS: These five consecutive cases aim to highlight the risk of LG misdiagnosis, in case of initial presentation with isolated inguinal adenitis. RESULTS: Five men (mean age: 30±7 years) were seen in an internal medicine department, for inguinal adenopathy. One patient had clinical signs of urethritis. None presented an associated rectitis. Three patients had a history of STI, and two had a discovery of related HIV disease. Urinary polymerase chain reaction (PCR) was positive for the symptomatic patient and negative for the others. Lymph node PCR was positive in all patients within a L2b serotype (searched in 4 out of 5 cases). CONCLUSION: LG should be evoked in any patient with inguinal adenomegaly, particularly in case of STI history or risk factors. Negativity of urinary PCR should lead to further investigations, essentially a lymph node cytopuncture to evidence C. trachomatis.
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Linfadenopatia/diagnóstico , Linfogranuloma Venéreo/diagnóstico , Adulto , Chlamydia trachomatis/genética , Chlamydia trachomatis/isolamento & purificação , Diagnóstico Diferencial , Humanos , Linfadenopatia/microbiologia , Linfogranuloma Venéreo/microbiologia , Masculino , Reação em Cadeia da Polimerase , Adulto JovemRESUMO
Uveomeningitis relates to an inflammatory state extending from iris and ciliary bodies to the choroid behind the eye. Because of a close contact between eye and brain, and barrier disruption, the inflammation can spread into the central nervous system (CNS). We review the clinical manifestations of uveitis, which are known to provide helpful clues to the diagnosis and describe the infectious, inflammatory, and neoplastic conditions classically associated with the uveomeningitis. Inflammatory or auto-immune diseases are probably the most common clinically recognized causes of uveomeningitis associated with a significant pleiocytosis. These entities often cause inflammation of various tissues in the body, including ocular structures and the meninges (i.e., sarcoidosis, Behçet's disease, and Vogt-Koyanagi-Harada syndrome). The association of an infectious uveitis with an acute or a chronic meningo-encephalitis is unusual but occasionally the eye examination may suggest an infectious etiology or even a specific organism responsible for an uveomeningitis. One should consider the diagnosis of primary ocular-CNS lymphoma in patients of 40 years of age or older with bilateral uveitis, especially with prominent vitritis, showing poor response to corticosteroid therapy. Finally, an algorithm for the diagnostic approach of uveomeningitis is proposed.
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Algoritmos , Síndrome Uveomeningoencefálica/diagnóstico , Síndrome Uveomeningoencefálica/terapia , Diagnóstico Diferencial , Infecções Oculares/complicações , Infecções Oculares/diagnóstico , Infecções Oculares/terapia , Humanos , Inflamação/complicações , Inflamação/diagnóstico , Inflamação/terapia , Meningite/diagnóstico , Meningite/etiologia , Meningite/terapia , Esclerose Múltipla/complicações , Esclerose Múltipla/diagnóstico , Esclerose Múltipla/terapia , Guias de Prática Clínica como Assunto , Sarcoidose/complicações , Sarcoidose/diagnóstico , Sarcoidose/terapia , Uveíte/diagnóstico , Uveíte/etiologia , Uveíte/terapia , Síndrome Uveomeningoencefálica/etiologiaAssuntos
Edema/complicações , Doença das Cadeias Pesadas/diagnóstico , Paraproteinemias/complicações , Insuficiência Renal/diagnóstico , Idoso , Diagnóstico Diferencial , Edema/diagnóstico , Doença das Cadeias Pesadas/complicações , Humanos , Extremidade Inferior , Masculino , Mieloma Múltiplo/complicações , Mieloma Múltiplo/diagnóstico , Paraproteinemias/diagnóstico , Insuficiência Renal/complicaçõesRESUMO
Biotherapies used in clinical practice for the treatment of ophthalmologic manifestations of systemic diseases include interferons (IFN), intravenous immunoglobulins (IVIG) and monoclonal antibodies (anti-TNF, anakinra, tocilizumab and rituximab). Several open prospective studies have shown the effectiveness of IFN-α (78 to 98% complete remission) for the treatment of severe uveitis in Behcet's disease. IFN is capable of inducing prolonged remission and continued after his arrest, in 20-40% of patients. Side effects (flu-like, psychological effects) limit its use in practice. Anti-TNFα (infliximab and adalimumab) represents an attractive alternative therapeutic in severe uveitis refractory to immunosuppressants, especially in Behcet's disease. They are almost always (>90% of cases) and rapidly effective but their action is often suspensive. Anti-TNFα requires an extended prescription or takes over from another immunosuppressant once ocular inflammation has been controlled. IVIG are used for the treatment of Kawasaki disease and Birdshot disease. Several open or retrospective studies showed their effectiveness for the treatment of severe and refractory cicatricial pemphigoid. Tolerance of IVIG is good but their efficacy is transient. Rituximab showed an efficacy in few observations of various inflammatory eye diseases (uveitis, scleritis and idiopathic inflammatory pseudo-tumors or associated with granulomatosis with polyangiitis) and cicatricial pemphigoid. The risk of infection associated with this biotherapy limits its use in refractory diseases to conventional therapy. Anakinra (a soluble antagonist of IL-1R) showed interesting results in terms of efficiency in one small open study in Behcet's disease. Its safety profile is good and with a quick action that could be interesting for the treatment of severe uveitis.
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Anticorpos Monoclonais/uso terapêutico , Terapia Biológica , Oftalmopatias/terapia , Imunoglobulinas Intravenosas/uso terapêutico , Inflamação/terapia , Interferons/uso terapêutico , Animais , Anticorpos Monoclonais/imunologia , Oftalmopatias/imunologia , Humanos , Imunoglobulinas Intravenosas/imunologia , Inflamação/imunologiaAssuntos
Hepatomegalia/diagnóstico , Berlim , Diagnóstico Diferencial , Equinococose Hepática/complicações , Equinococose Hepática/diagnóstico por imagem , Feminino , Granuloma/diagnóstico por imagem , Granuloma/etiologia , Hepatomegalia/diagnóstico por imagem , Humanos , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Radiografia , Cintilografia , Sífilis/complicações , Sífilis/diagnóstico , Viagem , Redução de Peso/fisiologiaAssuntos
Anemia Macrocítica/diagnóstico , Artralgia/etiologia , Síndromes Mielodisplásicas/tratamento farmacológico , Polimialgia Reumática/diagnóstico , Idoso de 80 Anos ou mais , Anemia Macrocítica/tratamento farmacológico , Deleção Cromossômica , Cromossomos Humanos Par 5 , Feminino , Humanos , Síndromes Mielodisplásicas/diagnóstico , Polimialgia Reumática/tratamento farmacológico , Redução de PesoRESUMO
The importance of fibroblast growth factor 23 (FGF 23) has been highlighted in the mechanism of urinary leakage of phosphate in the oncogenic osteomalacia (OO). It is now a component of diagnosis of this disease. We report a 58-year-old man who presented with osteomalacia and hypophosphatemia secondary to urinary leakage of phosphorus. Although serum FGF 23 was normal, the diagnosis of OO was obtained after another cause of acquired prolonged hypophosphatemia has been excluded (hyperparathyroidism and Fanconi syndrome in particular). The search for a deep tumor was performed, allowing the detection of a 12 mm hemangiopericytoma in the upper thigh. Its removal allowed the rapid resolution of clinical symptoms and laboratory abnormalities. The importance of functional sequelae in OO depends on prompt diagnosis. Tumorectomy remains the optimal treatment. Thus, the search for a secreting tumor is essential even in the absence of elevated serum FGF 23.
Assuntos
Fatores de Crescimento de Fibroblastos/biossíntese , Neoplasias de Tecido Conjuntivo/diagnóstico , Fator de Crescimento de Fibroblastos 23 , Humanos , Masculino , Pessoa de Meia-Idade , Osteomalacia , Síndromes ParaneoplásicasRESUMO
BACKGROUND: Restoration of immunocompetence in HIV-infected patients after antiretroviral treatment can have unexpected effects. CASE REPORTS: An unusual course of treated tuberculosis was observed in four HIV-infected patients soon after initiation of antiretroviral therapy. These patients developed fever and enlarged necrotic adenopathies despite an efficacious antituberculous therapy. They were in the initial stage of their antituberculous therapy that had been initiated a mean 12 days prior to initiation of antiretroviral therapy. The antiretroviral therapy led to an undetectable HIV load within 2 months. DISCUSSION: These unusual features, which also occurred with an increase in CD4 cell counts, could be related to the immunological restoration and to the reappearance of delayed type hypersensitivity. The onset of antiretroviral therapy could thus be delayed by several weeks in HIV-infected patients treated for active tuberculosis and who have never received antiretroviral therapy.