Infectious Uveitis Flashcards
stellate KP
HSV, VZV, Fuchs
chronic, unilateral anterior uveitis with irregular, slightly dilated pupil +/- iris atrophy
HSV and VZV
infectious anterior uveitis with high IOP
HSV, VZV, toxoplasmosis (cause trabeculitis)
acute unilateral vision loss. discrete foci of retinal necrosis involving peripheral retina that rapidly spread circumferentially, + vitritis + occlusive retinal arteriolitis +/- optic neuritis, scleritis, eye pain. otherwise healthy patient
ARN
progressive patchy outer retinal whitening, without vitritis, iritis, or vasculitis in immunocompromised patient? most common cause?
PORN. VZV (patients often w/ HIV)
salt and pepper fundus
rubella
headlight in fog fundus appearance (hazy vitritis overtop white retinal lesion)
toxoplasmosis
tx of herpetic uveitis
systemic antivirals, topical steroids (may need very long taper)
clinical variants of CMV retinitis
fulminant (+ hemorrhage and edema), granular (no hemorrhage or edema), frosted-branch (perivasculitis)
most common ocular manifestation of AIDS
HIV retinopathy
extraocular manifestations of congenital CMV
fever, thombocytopenia, anemia, pneumonitis, hepatosplenomegaly
most common cause of congenital viral infection
CMV
most common ocular manifestations of congenital and acquired EBV
congenital: cataract has been reported
acquired: self-limiting follicular conjunctivitis is most common
Classic features of congenital rubella syndrome? Most common ocular finding? Most common cause of vision loss? What two findings classically do not occur together?
- cardiac malformations, ocular findings (pigmentary retinopathy, nuclear cataract, glaucoma, microphthalmia, strabismus), and deafness.
- pigmentary retinopathy is most common but not visually significant, so cataract and microphthalmia are generally the causes of vision loss.
- classically, cataract and glaucoma do not occur together
presentation of acquired rubella (German measles)? most common ocular findings?
- fever, maculopapular rash that starts on face then spreads to whole body, lymphadenopathy
- conjunctivitis. less commonly keratitis and retinitis
how to differentiate between chorioretinitis from congenital toxoplasmosis v congenital LCMV (lymphocytic choriomeningitis virus)
intracerebral calcifications in LCMV are periventricular while they are diffuse in toxo
- most common ocular manifestations of acquired measles?
- other findings?
- findings in congenital measles?
- keratitis and mild, papillary, nonpurulent conjunctivitis.
- cataract, pigmentary retinopathy
- cataract, optic nerve drusen, diffuse pigmentary retinopathy
unvaccinated 5 year old develops vision loss, behavioral changes, and memory impairment: diagnosis and most common ocular finding
SSPE (subacute sclerosing panencephalitis), which is a rare, late complication of acquired measles. focal macular retinitis and RPE changes
presentation, ocular findings, and FA in West Nile virus
- febrile illness, myalgias, and in rare cases encephalitis. eye pain and redness, photophobia, blurred vision.
- multifocal chorioretinitis with +/- anterior and intermediate uveitis. characteristic linear lesions in midperiphery that follow retinal nerves
- inactive lesions appear targetoid on FA with central hypofluorescence but hyperfluorescence at the border
febrile illness in farmer or slaughterhouse worker + bilateral macular retinitis
Rift Valley Fever
Human T-Lymphocytic Virus Type 1 (HTLV-1) ocular finings. what cell does the virus invade? What else does this virus cause?
- unilateral vitritis, retinal vasculitis, and keratitis among others
- CD4+ T cells, causes adult T cell leukemia/lymphoma
most common mosquito-borne viral disease in? how do patients present?
Dengue fever. fever, petechial rash, bleeding problems form thrombocytopenia, headache, myalgia
most common ocular finding in Dengue fever? additional findings?
- petechial subconj heme
- maculopathy with intraretinal hemorrhages and periphlebitis
Indian immigrant presents with fever, arthralgias, anterior uveitis, pigmented KPs, and posterior retinochoroiditis
Chikungunya fever
4 diagnostic criteria of POHS
punched-out chorioretinal lesions, peripapillary atrophy, CNV, and absence of vitritis
Ohio or Mississippi River Valley
POHS
active form of Histoplasma capsulatum
yeast (not filament)
% chance of recurrent CNV within 5 years if recurrent histo-spots appear in macula? If no recurrent histo-spots?
15%
5%
most common cause of infectious posterior uveitis in adults and kids
toxoplasmosis
common modes of transmission for toxoplasmosis
ingestion of undercooked meat or contaminated water, contact with cat feces, blood transfusion or organ transplant, transplacental
hydrocephalus, diffuse intracerebral calcifications, and chorioretinitis in newborn
congenital toxoplasmosis
utility of toxoplasma serology
toxo is a clinical diagnosis, but a negative IgG rules it out (sensitive but not specific). IgG positive within 2 weeks of infection, and IgM persists for 1 year.
indications for treatment of ocular toxoplasmosis
- immunocompromised, congenital, acquired while pregnant
- lesion > 1 disc diameter in size
- perifoveal lesion
- CME
- multiple active lesions
- moderate to severe inflammation
- persistent active lesion for > 1 month
treatment of ocular toxoplasmosis
- pyrimethamine + sulfadiazine + prednisone (except not in newborns and pregnant) + folic acid +/- clindamycin
- bactrim + prednisone
classic fundus finding of toxocara
peripheral retinal granuloma with a fibrous band extending to the optic nerve
risk factors for toxocara transmissoin
contact with dog or cat feces, playgrounds and sand boxes
treatment of toxocara
periocular and/or systemic steroids. no antimicrobials
most common ocular tapeworm infection, name of the worm, and method of transmission?
cysticercosis, Taenia solium, ingestion of undercooked pork
white vitreous or subretinal cyst with a motile body that reacts to light. extraocular findings?
cysticercosis. CNS involvement can lead to seizures
cause and vector of river blindness
Onchocerca volvulus. black fly
treatment of river blindness
Ivermectin to kill microfilaria, doxycycline to the kill adult worm (by killing the parasitic bacteria Wolbachia which is critical for sexual development of the worm)
subcutaneous skin nodules and uveitis in patient from sub-Saharan Africa
River Blindness (Onchocerca volvulus)
Hutchinson’s triad for congenital syphlis. Most common sign of untreated late congenital syphilis?
- Hutchinson’s teeth, deafness, interstitial keratitis
- nonulcerative stromal interstitial keratitis
In what stages of syphilis do the following occur:
- uveitis
- lymphadenopathy
- maculopapular rash including palsm and soles
- painless chancre
- gummas on skin, choroid, iris
- neurosyphilis
- 2 or 3
- 2
- 2
- 1
- 3
- 3
testing for syphilis? In infant of mother with syphilis? False positives?
- Either RPR or VRDL (nontreponemal tests) and either FTA-ABS or MHA-TP (treponemal tests). Always test for HIV in patients with confirmed syphilis. Always get LP in patients with syphilitic uveitis
- FTA-ABS IgM in infants, because IgG from infected mother will cross placenta
- nontreponemal test false positives: SLE, leprosy, other spirochete infections, pregnancy, among others
- treponemal test false positives: more rare. other spirochete infections, SLE, RA, leprosy, malaria
What is an Argyll Robertson pupil?
light-near dissociation (constricts on accommodation but not in response to light). very common in tertiary syphilis
treatment of syphilitic uveitis? treatment of primary or secondary syphilis?
- treat as if patient has neurosyphilis: IV penicillin G x 10-14 days
- IM penicillin G x 1
- don’t forget to treat sexual partner (for prevention), and to alert appropriate health authorities (reportable disease)
fever, chills, hypotension, tachycardia within 24 hours of receiving penicillin for syphilis? management?
Jarisch-Herxeimer reaction (immune response to large number of recently killed spirochetes). Supportive care, steroids as needed
treatment for penicillin allergic patient with neurosyphilis?
penicillin desensitization therapy and then IV penicillin x 10-14 days. can try doxy or tetracycline only for penicillin allergic patients who do not have neurosyphilis.
Findings of 3 stages of Lyme Disease
- erythema chronicum migrans (bull’s eye rash), constitutional symptoms, follicular conjunctivitis
- disseminated involvement: skin, CNS (meningitis, encephalitis, Bell’s palsy), joints, heart, eyes. arthritis most prominent, especially large joints like knee. uveitis usually in this stage if it occurs
- episodic arthritis, chronic neurologic symptoms. keratitis. uveitis less common in this stage
diagnosis of Lyme disease?
ELISA with confirmatory Western blot. LP to eval for CNS involvement if patient with confirmed Lyme uveitis
treatment of Lyme?
oral doxy for patients older than 8, amoxicillin for younger kids. IV ceftriaxone for CNS and cardiac involvement. topical steroids and mydriatics for uveitis
tropical farmer with abrupt onset of constitutional symptoms +/- more severe signs of sepsis, and with circumcorneal conjunctival hyperemia and uveitis
leptospirosis
vitreous culture reveals gram-positive, partially acid fast bacteria with branching filaments: diagnosis and treatment
Nocardiosis. bactrim
fever, night sweats, weight loss, phlyctenulosis, keratitis, mutton fat KP, iris nodules, uvieits
TB
noninfectious cause of posterior uveitis that TB most closely mimics
serpiginous
percentage of people worldwide infected with TB?
percentage of affected patients who have symptoms?
33%
10%
obliterative peripheral periphlebitis in young otherwise healthy males presenting with recurrent retinal and vitreous heme? microbial etiology?
Eales disease. Possible association with TB
What does a positive PPD or quantiferon test indicate?
Positive PPD cutoffs?
- prior exposure to TB (includes BCG vaccine)
- 5mm for high risk (HIV, exposed to active TB)
- 10mm for intermediate risk (healthcare workers, diabetes, renal disease, immigrants from endemic countries, taking IMT)
- 15mm for low risk
8 year old kid with constitutional symptoms and unilateral granulomatous conjunctivitis with regional lymphadenopathy
Parinaud oculoglandular syndrome caused by Bartonella henselae (cat scratch disease)
unilateral optic nerve swelling, macular star, white retinal lesions, vitritis: diagnosis and treatment
neuroretinitis from cat scratch fever (Bartonella henselae). Tx = doxycycline, or azithromycin if under 8 years old.
50 year old male with migratory arthritis and chronic diarrhea with bilateral panuveitis and retinal vasculitis: diagnosis, diagnostic test, and treatment.
Whipple disease. Duodenal biopsy is confirmatory. bactrim
cells infected by HIV
CD4+ T cells and macrophages
Diagnosis of HIV
ELISA w/ confirmatory Western blot
CD4 level where symptoms generally start to develop
Antiretroviral treatment algorithm for HIV
2 x NRTI + NNRTI + PI
5 classes of HIV-related ocular disease. Most common?
HIV retinopathy (most common) opportunistic infections conjunctival SCC lymphoma of retina or orbit Kaposi sarcoma of eyelid and conj
3 most important HIV-related opportunistic pathogens causing retinitis
CMV, VZV, toxoplasma
fundus findings of HIV retinopathy
cotton wool spots, retinal hemorrhages, and microaneurysms
CD4 level below which CMV retinitis manifests
drug associated with increased risk of immune recovery uveitis (IRU). other related side effect of this drug?
cidofovir. also can cause anterior uveitis and hypotony syndrome in absence or IRU
HIV patient started on antiretroviral therapy and CD4 increases from 50 to 100. Patient then develops uveitis
immune recovery uveitis associated with CMV
major complication of CMV retinitis
retinal detachment (up to 50%)
pale yellow placoid macular lesions in AIDS patient
syphilis
hemorrhagic conjunctival mass in HIV patient
Kaposi sarcoma, HHV8
