PRESUMED PANUVEITIS FOLLOWING COVID-19 VACCINATION IN A PATIENT WITH GRANULOMATOUS TATTOO INFLAMMATION.

PURPOSE: To report a case of panuveitis that developed following COVID-19 vaccination in a patient with a recent history of granulomatous tattoo inflammation. METHODS: Case report. RESULTS: A 25-year-old woman with a recent history of biopsy-proven granulomatous tattoo inflammation developed bilateral eye pain and blurred vision 1 week following her second mRNA-1273 COVID-19 vaccination (Moderna, Inc, Cambridge, MA). Examination revealed bilateral panuveitis. Workup for infectious etiologies and sarcoidosis was negative. The intraocular inflammation initially resolved with systemic prednisone therapy but then recurred following tapering, requiring the initiation of mycophenolate mofetil. CONCLUSION: A case of panuveitis that developed following a COVID-19 vaccination in a patient with a recent history of tattoo inflammation is reported. The temporal relationship between the vaccine and the development of uveitis in this patient may be coincidental and should be interpreted with caution, but multiple vaccines have been associated with uveitis, presumably as a result of their generalized stimulation of the immune system. It is believed that this case of tattoo-associated uveitis may have been exacerbated by the generalized inflammatory effect of COVID-19 vaccination.

Bilateral Granulomatous Panuveitis in A Patient with COVID-19.

PURPOSE: To present a case of panuveitis with granulomatous intraocular inflammation and vasculitis related to coronavirus disease 2019 (COVID-19). CASE REPORT: A 46-year-old female patient had blurred vision in both eyes during 8 days after COVID-19 symptoms. Anterior segment examination revealed anterior chamber cells in the both eyes, mutton fat keratic precipitates and posterior synechiae in the left eye. Small peripheral iris nodules and mild vitritis were accompanying in both eyes. Fundus examination revealed multiple superficial retinal infiltrate lesions in the peripheral retina with retinal periphlebitis in both eyes. Spectral domain optical coherence tomography showed hyperreflective superficial retinal infiltrates. Fluorescein angiography (FA) and indocyanine green angiography demonstrated hypofluorescent foci due to blockade of retinal infiltrates. Peripheral vascular leakage was detected on FA in both eyes. CONCLUSION: This case showed that COVID-19 infection can cause granulomatous panuveitis. Autoimmune mechanisms related to COVID-19 may lead to ocular inflammation.

Unusual Presentation of Skin Tattoo-Associated Panuveitis.

AIM: We report a case of a young male who developed bilateral panuveitis after extensive tattooing. DESIGN: Case report. METHODS: A 22-year-old male with a history of inflamed tattoos presented with pain in both eyes and blurred vision in the left eye. Clinical examination showed ciliary congestion, flare, vitreous cells in both eyes, and posterior synechiae in the left eye. Optic nerve was swollen in both eyes. OCT scans demonstrated subretinal blood, associated with neurosensory macular detachment in the left eye. The skin tattoo biopsy showed a granulomatous inflammation without evidence of sarcoidosis. Long-term corticosteroid therapy allowed a regression of clinical signs and symptoms with full recovery. CONCLUSION: TAttoo Granulomas with Uveitis (TAGU) is a syndrome with numerous clinical presentations. In our case, optic nerve head oedema and subretinal hemorrhage at the posterior pole were the presentation signs. Ophthalmologists should always consider TAGU as a diagnosis in patients with a history of inflamed tattoos.

[OCULAR SARCOIDOSIS].

INTRODUCTION: A 68-year-old healthy female, with no past systemic or ocular history, presented with decreased vision in both eyes. On initial examination, there were extensive vitreal opacities in both eyes. On the following visit, bilateral panuveitis was newly observed, without otherwise systemic clinical manifestations. The patient responded well to treatment with systemic and topical steroids. Initial workup excluded tuberculosis and syphilis. Angiotensin-converting enzyme (ACE) was within normal range. In order to make a definitive diagnosis and to exclude lymphoma, we decided to perform a vitreous biopsy after 2-weeks of steroids withdrawal. After cessation of steroids, new lesions appeared beneath the right eye and over the nasal bridge. Moreover, iris nodules over the stroma, pupil's margin and anterior chamber angle were noticed in both eyes. Biopsy from a skin lesion demonstrated non-caseating granulomas, supporting diagnosis of sarcoidosis. A chest computed tomography (CT) scan demonstrated compatible radiologic findings of bilateral hilar and mediastinal lymphadenopathy. Sarcoidosis is a chronic multisystem, autoimmune, granulomatous disease. Ocular involvement is common among patients with sarcoidosis, with the most common ocular manifestation being uveitis. We report a case that presented with bilateral panuveitis due to sarcoidosis with no systemic manifestations or elevated serum biomarkers. Definitive diagnosis was verified in histopathological findings from a skin biopsy and radiological findings in chest CT.

Pediatric inflammatory multisystem syndrome induced Panuveitis associated with SARS-CoV- 2 infection: What the Ophthalmologists need to know.

The diagnosis of bilateral panuveitis was made in a 9-year-old girl who was referred to our hospital for blurred vision accompanied by periorbital and abdominal pain. Endothelial dusting, vitreous haze and optic nerve edema were deemed as signs of involvement of all segments of the eye. The bloodwork results were suggestive of infectious uveitis, with elevated inflammatory markers and the patient was treated with IV antibiotics. Cerebral-CT was normal, screening for common infectious causes of uveitis and cultures were negative. There was no history of autoimmune disease, and autoimmune antibody tests were negative. Pediatric inflammatory multisystem syndrome induced panuveitis, secondary to SARS-CoV-2 (PIMS), was suspected by the infectious disease consultant. The syndrome commonly affects school-age children and represents a generalized inflammatory response in the body that appears about one month after the initial infection with the SARS-CoV-2 virus. Initial symptoms include fever, abdominal pain, eye redness, rashes, dizziness, accompanied by laboratory evidence of inflammation unexplained by any other plausible cause. The patient's coronavirus IgG titer was positive, while the RT-PCR for SARS-CoV-2 virus, taken from the nasopharyngeal swab, was negative. As all the other investigations turned out negative, COVID-19 was the only presumptive cause for the pediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 (PIMS-TS). A diagnosis of probable COVID-19 induced uveitis was made and the patient started IV Dexamethasone, followed by oral steroids that were gradually tapered and made a full recovery. The aim of this report was to shed light and enrich the scarce literature available on Uveitis as a sign of pediatric inflammatory syndrome following COVID-19 infection. Abbreviations: ACE2 = Angiotensin converting enzyme 2, ANA = Antinuclear antibodies, c-ANCA, p-ANCA = Cytoplasmic and perinuclear anti-neutrophil cytoplasm antibodies, BCVA = Best corrected visual acuity, CMV = Cytomegalovirus, COVID-19 = coronavirus disease 2019, CRE = Carbapenem-resistant Enterobacteriaceae, CRP = C-Reactive Protein, EBV = Epstein Barr virus, ESBL = Extended spectrum beta-lactamase, ESR = Erythrocyte Sedimentation Rate, FCoV = Feline coronavirus, MDR = Multidrug resistant, MRSA = methicillin-resistant Staphylococcus aureus, MHV = mouse hepatitis virus, MIS-C = multisystem inflammatory syndrome in children, NSAID = Nonsteroidal anti-inflammatory drug, NT pro BNP = precursor natriuretic brain peptide, PIMS-TS = Pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2, RNFL = Retinal nerve fiber layer, SARS CoV-2 = severe acute respiratory syndrome coronavirus 2, SD-OCT = Spectral domain optical coherence tomography, VRE = Vancomycin-resistant Enterococci.

Complications of uveitis in a Spanish population, UveCAM study.

OBJECTIVE: To estimate the population frequency of uveitis complications and to evaluate their main risk factors in the patients with uveitis from the UVECAM study. PATIENTS AND METHODS: Development of complications in 386 patients with uveitis in the whole health area of the province of Toledo (UVECAM study) during a period of 1 year. Description of complications and study of their possible determinants by means of multivariate regression models. RESULTS: Information on the development of complications was available in 371 of the 386 patients of the UVECAM study. The most frequent complications were posterior synechiae (19.0%), ocular hypertension (14.0%), macular edema (7.5%), epirretinal membrane (6.9%), glaucoma (6.6%), iridian atrophy (5.6%) and cataract (5.5%). The risk of complications increases with age, intermediate and panuveitis locations, and those of chronic or recurrent evolution. CONCLUSION: Uveitis is associated with a high frequency of complications, especially in older patients, with intermediate or posterior localization of the inflammatory process and chronic or recurrent evolution.

Cooperation with rheumatologists on intensive systemic treatment for psoriatic arthritis-related panuveitis with retinal vasculitis: a case report.

BACKGROUND: Patients with psoriatic arthritis (PsA) may develop uveitis, a potentially serious ocular complication. PsA-related uveitis may result in significant morbidity and even vision loss if underdiagnosed or under-treated. We presented a case with long-standing recurrent uveitis and retinal vasculitis successfully managed by fortified systemic immunomodulators for systemic PsA. CASE PRESENTATION: A 47-year-old woman was referred under the impression of acute anterior uveitis in her right eye in recent one month. Ocular examinations showed panuveitis in both eyes with intense vitreous opacity in her right eye. Fundus fluorescence angiography revealed retinal vasculitis in both eyes. Systemic surveys excluded the possibility of infection but showed an elevated inflammation marker. With intensive immunosuppressive treatment, inflammation resolved and the vision improved. CONCLUSION: Our case highlights not only the importance of intensified systemic therapy in treating PsA-related uveitis but the importance of multidisciplinary collaboration. Recurrent uveitis may be an indicator of disease activity prior to other inflammatory markers.

Granulomatous panuveitis associated with Hodgkin lymphoma: A case report with review of the literature.

BACKGROUND: Intraocular lymphoma (IOL) is an uncommon ophthalmic malignancy and poses a diagnostic challenge. Uveitis associated with systemic lymphoma (USL) has been predominantly attributed to non-Hodgkin lymphoma (NHL) and rarely reported with Hodgkin lymphoma (HL) in the literature. METHODS: Case report with review of the literature. RESULTS: A 25-year-old healthy male presented with bilateral granulomatous panuveitis including vasculitis and discrete chorioretinal yellowish-white lesions. Macular optical coherence tomography (OCT) of both eyes revealed a disruption of ellipsoid and interdigitation zones over the areas of subretinal lesions as well as a small sub-retinal pigment epithelium (RPE) deposit in one eye. Thorough uveitis workup revealed clavicular, axillary and cervical lymphadenopathy, and biopsy of lymph nodes confirmed the diagnosis of nodular lymphocyte-predominant (NLP) HL. Six months later and after receiving chemotherapy, all symptoms and most of clinical signs resolved. CONCLUSIONS: Clinical features of USL do not differ between HL and NHL. However, the age of presentation may be much younger in HL. Ocular manifestations can precede systemic HL diagnosis, as shown in our patient. Therefore, USL should be part of the differential diagnosis of panuveitis. Paraneoplastic inflammation is thought be the cause of uveitis associated with HL. The sub-RPE deposit and disruption of ellipsoid and interdigitation zones on OCT have not been documented before as a manifestation of uveitis secondary to HL. In addition, the NLP subtype of HL was reported in only 1 case with uveitis in the literature.

Post COVID-19 Ophthalmic Manifestations in an Asian Indian Male.

Introduction: The Ocular manifestations of coronavirus disease 2019 (COVID-19) reported include conjunctivitis, conjunctival hyperemia, chemosis, epiphora, episcleritis, retinal manifestations included cotton wool spots (CWS), micro-hemorrhages, papillophlebitis and neuro-ophthalmic manifestations.Purpose: To report post COVID-19 ophthalmic manifestations using multimodal imaging.Results: A 66-year-old Asian Indian male presented to us with bilateral blurring of vision, RE>LE, of 3 days following a diagnosis of COVID-19 disease. Corrected distance visual acuity were 20/2666 and 20/25 in the right (RE) and left (LE) eyes respectively. He had bilateral anterior chamber inflammation with a relative afferent pupillary defect in the RE. RE showed central retinal artery occlusion(CRAO) with CWS, few flame-shaped retinal hemorrhages and disc edema and hyperemia. LE had disc edema and hyperemia, few flame-shaped retinal hemorrhages, cystoid changes and CWS. A diagnosis of bilateral panuveitis and papillitis with CRAO in the RE was made.Conclusion: Our patient developed a vascular occlusion with panuveitis, which possibly represents an immune mediated event following COVID-19. Patients should be warned about possible ophthalmic sequelae even after recovery.

A novel mutation in early-onset sarcoidosis/Blau syndrome: an association with Propionibacterium acnes.

BACKGROUND: Early-onset sarcoidosis (EOS) and Blau syndrome (BS) are systemic inflammatory granulomatous diseases without visible pulmonary involvement, and are distinguishable from their sporadic and familial forms. The diseases are characterized by a triad of skin rashes, symmetrical polyarthritis, and recurrent uveitis. The most common morbidity is ocular involvement, which is usually refractory to conventional treatment. A gain-of-function mutation in the nucleotide-binding oligomerization domain-containing protein 2 (NOD2) gene has been demonstrated in this disease; however, little is known about the relationship between the activation of NOD2 and the pathophysiology of EOS/BS. Here we describe EOS/BS with a novel mutation in the NOD2 gene, as well as detection of Propionibacterium acnes (P. acnes) in the granulomatous inflammation. CASE PRESENTATION: An 8-year-old Japanese girl presented with refractory bilateral granulomatous panuveitis. Although no joint involvement was evident, she exhibited skin lesions on her legs; a skin biopsy revealed granulomatous dermatitis, and P. acnes was detected within the sarcoid granulomas by immunohistochemistry with P. acnes-specific monoclonal (PAB) antibody. Genetic analyses revealed that the patient had a NOD2 heterozygous D512V mutation that was novel and not present in either of her parents. The mutant NOD2 showed a similar activation pattern to EOS/BS, thus confirming her diagnosis. After starting oral prednisolone treatment, she experienced an anterior vitreous opacity relapse despite gradual prednisolone tapering; oral methotrexate was subsequently administered, and the patient responded positively. CONCLUSIONS: We presented a case of EOS/BS with a novel D512V mutation in the NOD2 gene. In refractory granulomatous panuveitis cases without any joint involvement, EOS/BS should be considered as a differential diagnosis; genetic analyses would lead to a definite diagnosis. Moreover, this is the first report of P. acnes demonstrated in granulomas of EOS/BS. Since intracellular P. acnes activates nuclear factor-kappa B in a NOD2-dependent manner, we hypothesized that the mechanism of granuloma formation in EOS/BS may be the result of NOD2 activity in the presence of the ligand muramyl dipeptide, which is a component of P. acnes. These results indicate that recognition of P. acnes through mutant NOD2 is the etiology in this patient with EOS/BS.

Manifestation of Panuveitis after Intraocular Surgery in a Child with Blau Syndrome.

Blau syndrome (BS) is a rare granulomatous disease with autosomal dominant inheritance. It is characterized by a triad of dermatitis, arthritis, and recurrent uveitis. This case presents the onset of panuveitis in BS after intraocular surgery. A 10-year-old boy presented to the outpatient clinic with retinal detachment in the left eye after 6 years following early-onset cataract surgery. Bilateral panuveitis occurred 3 weeks after surgical repair and resulted in a total visual loss in the left eye and was persistent to conventional treatment in the right eye. Genetic testing revealed a mutation in NOD2 gene. The addition of adalimumab to the treatment regimen resulted in long-term uveitis control and maintenance of 20/70 vision in the right eye. We propose that NOD2-mediated inflammatory cascade can be activated by intraocular surgery and results in the manifestation of BS.

ACUTE MYOCARDITIS WITH CARDIOGENIC SHOCK AND MULTIPLE ORGAN FAILURE, FOLLOWED BY BILATERAL PANUVEITIS MASQUERADING AS ENDOGENOUS ENDOPHTHALMITIS, DUE TO TOXOPLASMA GONDII IN AN IMMUNOCOMPETENT PATIENT.

PURPOSE: To report a case of systemic and ocular toxoplasmosis in an immunocompetent patient, who developed myocarditis with resulting cardiogenic shock and multiple organ failure, followed by bilateral panuveitis masquerading as endogenous endophthalmitis. METHODS: Single case report with images. RESULTS: A 59-year-old man with a history of monoclonal gammopathy of undetermined significance and associated scleromyxedema but otherwise immunocompetent was admitted to the intensive care unit for cardiogenic shock and multiple organ failure due to presumed viral myocarditis. After hospital discharge, ophthalmic examination revealed what seemed to be endogenous fungal endophthalmitis in both eyes. The ocular inflammation failed to improve on local and systemic antifungal therapies. After repeated testing and vitrectomy, the causative organism responsible for his intraocular inflammation remained elusive. The patient was then found to have significantly elevated serum titers of anti-Toxoplasma gondii IgG and IgM, followed by an appearance of a focal retinochoroidal lesion more typical of ocular toxoplasmosis. Systemic anti-Toxoplasma therapy led to resolution of intraocular inflammation, and the patient had since fully recovered from the myocarditis and its multiple comorbidities. Of note, myocardial biopsy and polymerase chain reaction testing of aqueous and vitreous fluids were all negative for Toxoplasma. CONCLUSION: Even in an immunocompetent patient, Toxoplasma can result in myocarditis with significant morbidities and even death, and its ocular manifestation may be quite different from the classic focal retinochoroiditis. In addition, polymerase chain reaction analysis of ocular fluids can be unreliable in an immunocompetent host, and thus treatment decision should be guided by clinical history and examination findings.

Panuveitis revealing Melkersson Rosenthal syndrome: a case report.

AIM: To describe a case of panuveitis revealing Melkersson Rosenthal syndrome (MRS). CASE REPORT:   A 35-year-old female with a history of bilateral chronic idiopathic panuveitis was referred for work up. On examination, her visual acuity was 3/10 in the right eye and limited to hand motion in the left eye. Slit lamp examination revealed posterior synechiae and vitritis more severe in the left eye. Fundus examination showed bilateral vascular sheathing with no retinitis or choroiditis. Fluorescein angiography revealed bilateral occlusive retinal vasculitis. A careful questioning of the patient revealed the history of relapsing facial paralysis with palpebral edema. The work up ruled out an underlying infectious disease, especially ocular tuberculosis. Examination of the internist revealed a cheilitis and a fissured tongue. The diagnosis of MRS was made and the patient was treated with systemic corticosteroids and scatter laser treatment of retinal nonperfusion areas. CONCLUSION: MRS is a rare disorder. Ocular involvement, especially uveitis, is uncommon. Clinicians should be aware of this syndrome to avoid misdiagnosis and extensive work up.

Diagnostic vitrectomy: a case series in a single referral center. / Vitrectomía diagnóstica: serie de casos en un centro de referencia.

OBJECTIVE: To study the results and safety of diagnostic vitrectomy in patients with unknown etiology panuveitis. METHODS: A retrospective descriptive observational study was carried out in which a total of 29 patients (37 eyes) were included, who underwent a vitreous biopsy due to acute intraocular inflammatory processes. In all, demographic and clinical data were collected. We studied the specific samples extraction methods and their diagnosic processing. RESULTS: Of the 29 patients analyzed, 18 were men. Mean of age was 63.11 years old (standard deviation: 14.55). The most frequent initial symptom was visual acuity decrease, with mean initial visual acuity being 20/40, excluding 8 eyes that had vision lower than 20/200. 21 presented unilateral ocular involvement. Vitrectomy was performed in all of them obtaining a dry sample. Vitrectomy was performed in all of the patients obtaining a dry sample. Moreover, the following techniques were done: 5 retinal biopsies, obtaining 5 muestras diluidas, 1 subretinal abscess aspirate and 1 aqueous humor aspirate. The most frequent processing technique that was used was cytology in 25 eyes, followed by PCR (polymerase chain reaction) in 11 eyes and culture in 10 eyes. Diagnosis was achieved in 94.5% of patients. Main diagnosis found was lymphoma, followed by toxoplasmosis. CONCLUSIONS: Diagnostic vitrectomy is very important in ophthalmic inflammation identification. Different techniques for obtaining and processing can be used.

Clinicopathological and immunohistochemistry correlation in a case of Vogt-Koyanagi-Harada disease.

Vogt-Koyanagi-Harada (VKH) disease is a systemic disorder causing bilateral panuveitis. Histopathological documentation along with molecular diagnostic evidence in VKH eye is a rarity. We present a 46-year-old woman with VKH with several ocular complications and subsequently enucleation of the right eye was done because of painful blind eye. Patient had clinical complications of VKH and some of the complications were observed in histopathology. Pathology of the case showed nongranulomatous uveitis, indicating the disease in chronic recurrent stage. Immunohistochemistry showed predominant T-cell involvement in this case. The case showed clinicopathological and immunohistochemistry correlation in a case of VKH disease.

Tattoo-associated panuveitis: A 10-year follow-up.

INTRODUCTION: There has been an increasing number of tattoo-related uveitis without evidence of systemic sarcoidosis. This finding may indicate a possible association of tattoos with uveitis. CASE DESCRIPTION: This report is a 10-year follow-up of a single case of tattoo-related uveitis with no proven systemic sarcoidosis. CONCLUSION: Literature review suggests possible pathogenesis and the patient's management is discussed. This case highlights the importance of a good systemic history and physical examination, especially with regard to tattoos.

A case of recalcitrant pediatric Vogt-Koyanagi-Harada disease successfully controlled with adalimumab.

Vogt-Koyanagi-Harada (VKH) disease is uncommon in the pediatric population and can have an aggressive course with serious visual sequelae. A 12-year-old Han Chinese American female, who presented with mild headaches and panuveitis with diffuse serous retinal detachments, was diagnosed with VKH. Despite treatment with a combination of high-dose systemic corticosteroids, intravitreal triamcinolone injection, and mycophenolate mofetil, ocular inflammation was inadequately controlled. Addition of adalimumab allowed for inflammation remission, improvement of vision, and tapering of systemic corticosteroids. Escalation of immunosuppression until remission appears to be critical in this population. Further research is needed to understand the complex pathophysiology of VKH and investigation for similar efficacy of other anti-tumor necrosis factor-alpha agents will need to be performed.

Vision-threatening bilateral panuveitis and TRAPS in a child: an uncommon association.

PURPOSE: To report a childhood case of tumor necrosis factor receptor-associated periodic syndrome (TRAPS) carrying the R92Q variant with a vision-threatening bilateral panuveitis. METHODS: Case report and review of the literature. RESULTS: A 7-year-old boy presented with an active bilateral panuveitis and a macular rash associated with fever. Fundus examination showed two choroidal lesions on the posterior pole of the right eye, and fluorescein angiography revealed early hypofluorescence and late hyperfluorescence of the lesions, which were hyper-autofluorescent. Extensive clinical laboratory analyses ruled out autoimmune diseases and systemic infection. The only remarkable finding was a positive IgG for herpes simplex 1. He underwent two successive diagnostic pars plana vitrectomies as well as cataract and glaucoma surgeries. Genetic analysis revealed a mutation in the TNFRSF1A gene, and the patient was diagnosed with TRAPS-associated bilateral panuveitis. He was treated with adalimumab and has been free of active inflammation since then. CONCLUSIONS: We present here the first case reported of panuveitis in a patient with TRAPS. This finding stresses the increasing importance of genetic analysis in search of autoinflammatory diseases to establish an adequate diagnosis and treatment in cases of uveitis of unknown etiology.

Ocular Autoimmune Systemic Inflammatory Infectious Study - Report 3: Posterior and Panuveitis.

PURPOSE: To report the pattern of posterior and panuveitis at a tertiary referral center in Singapore. METHODS: Subgroup retrospective analysis of 334 new posterior and panuveitis cases, from the Ocular Autoimmune Systemic Inflammatory Infectious Study (OASIS) database. Descriptive analysis was performed and visual outcome and complications were reported. RESULTS: The etiology for posterior uveitis and panuveitis was infectious in 162 patients (48.5%), non-infectious in 144 patients (43.1%), and idiopathic in 28 patients (8.4%). More patients with bilateral disease had a non-infectious etiology (n = 82, 50.9%) (p = 0.012). The most common complication was epiretinal membrane (n = 20, 12.3%) for the infectious group and cystoid macular edema (n = 12, 8.3%) for the non-infectious group. CONCLUSIONS: The proportion of etiologies in our cohort varies from other studies. Understanding the variations and demographic associations allows the diagnosis and management of posterior and panuveitis to be further improved.