A 17-year-old Eritrean girl presented with a 5-day history of redness, tearing, and photophobia which started in her right eye (OD) and then involved her left (OS). She recalled similar, but less severe symptoms over the 2 months prior to presentation. Her medical history was significant for acute myeloid leukemia diagnosed 5 years earlier. She was treated with chemotherapy and received an allogeneic hematopoietic stem cell transplant 6 months after diagnosis. She developed graft-versus-host-disease (GVHD) of the gastrointestinal tract, lungs, and skin with mild ocular surface involvement, but these issues were stable at the time of presentation to the eye clinic.
On initial examination, pinhole visual acuity was 20/32 in each eye (OU), and intraocular pressures were 14 mmHg OU. Small non-granulomatous keratic precipitates were present OU. The anterior chambers had 3+ and 4+ cells (OD and OS, respectively), and bilateral moderate vitritis was noted. The left eye also had a hypopyon (less than 1 mm) and posterior synechiae of the iris (Fig. 1). Both eyes were treated with topical prednisolone acetate 1% every hour and cyclopentolate twice daily. Due to the concern for recurrent leukemia or infection, aqueous humor was obtained from the left eye; cytology was negative for malignant cells, and cultures were negative. Laboratory testing was negative or within normal limits for RPR, syphilis IgG, hepatitis B and C, angiotensin-converting enzyme, lysozyme, ANA, anti-dsDNA, rheumatoid factor, and HLA-B27. The uveitis resolved after 2 weeks of intensive topical corticosteroids.
Topical corticosteroids were tapered to every 2 hours OU. Ten days later, the patient developed recurrent bilateral anterior uveitis and vitritis with a hypopyon OS. Fluorescein angiography (FA) showed diffuse retinal vascular leakage and late staining of the optic nerves in both eyes (Fig. 2a, b). A more detailed review of her medications and medical history revealed she was on rifabutin for recurrent MAC. Nearly 2 years before she developed uveitis, she had completed a 9-month course of ethambutol, clarithromycin, and rifabutin for MAC cultured from a lung biopsy. During the same period, she was on systemic immunosuppressive medications (mycophenolate mofetil, cyclosporine, and prednisone) for GVHD. Eight months before presenting with hypopyon uveitis, ethambutol, clarithromycin, and rifabutin were restarted for recurrent MAC. Rifabutin dosing was twice as high (300 mg every Monday, Wednesday, and Friday), and she was no longer on systemic immunosuppressive agents. After rifabutin-associated uveitis was diagnosed, her medication was switched from rifabutin to moxifloxacin. Topical corticosteroids were continued at the same frequency (every 2 hours), and the hypopyon resolved 5 days later. In the first 2 weeks of follow-up, the macular edema initially worsened, OS > OD, but over time, the thickening gradually returned to normal (Fig. 3). On fluorescein angiography, the diffuse retinal leakage had improved at 5 weeks and had resolved after 4 months on a slow topical corticosteroid taper (Fig. 2c–f).