The patient is a 42-year-old African-American female with a 20-year history of a chronic idiopathic non-granulomatous anterior uveitis. Her medical history includes hypertension and genital and oral herpes, for which she was maintained on valcyclovir. Her previous evaluations for the uveitis included non-reactive FTA-ABS and RPR, negative tuberculin skin test, negative serologies of ANCA, ANA, anti-double stranded DNA, rheumatoid factor, Lyme EIA, and normal ACE level, gallium scan and chest X-ray.
Biweekly adalimumab 40 mg injections were initiated because of persistent inflammation of her right eye, despite being treated with steroid-sparing agents, methotrexate then mycophenalote mofetil. Four days after receiving her second injection, she presented with “fuzzy vision” of her right eye. Her visual acuity was reduced to 20/50 with a small right relative afferent pupillary defect, dyschromatopsia, and no pain with movement. Her fundus examination revealed an optic nerve without edema or hemorrhage. Formal visual field testing demonstrated a right superior altitudinal field defect. A brain and orbital magnetic resonance imaging (MRI) with gadolinium showed multiple callosal, pericallosal, periventricular, subcortical, right cerebellar lobe, and left occipital lobe T2/FLAIR lesions with enhancement and restricted diffusion (Fig. 1). Her vision declined to counting fingers and she received methylprednisolone 1 g/day for 3 days followed by a tapering course of prednisone. A lumbar puncture was performed; the CSF was clear and positive for oligoclonal bands. IgG index was elevated to 13.7 (0.8–7.7). Further laboratory evaluation was negative for HTLV I/II, HIV, and HCV antibodies, HBcAg and sAg, Lyme titers and non-reactive to RPR. Her extended review of systems and the remainder of her neurologic examination were unremarkable.
Within a few weeks, she experienced complete resolution and subsequent follow-up visual fields have been full. Six months afterwards, repeat imaging demonstrated no significant interval change in the multiple T2/FLAIR foci of hyperintensities. Several of the lesions still had faint restricted diffusion. Our patient has remained symptom free and has started on immunomodulatory therapy.