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Uveitis > Systemic > Flashcards

Systemic Flashcards

0
Q

Reactive arthritis

A

Reactive arthritis is associated with two types of infection: (1) post-dysentery caused by Gram-negative bacteria (e.g. Shigella, Salmonella, Yersinia, Campylobacter); and (2) post-venereal (e.g. caused by Chlamydia).

The classic triad of reactive arthritis are: urethritis, polyarthritis, and conjunctivitis. The medical student way to remember this is: “can’t see, can’t pee, can’t climb a tree”.

A mucopurulent and papillary conjunctivitis is the most common ocular manifestation of reactive arthritis. This conjunctivitis can be associated with a mucocutaneous discharge but without a swollen preauricular node. Other ocular signs include iritis, a punctate epithelial keratitis, and anterior stromal infiltrates.

Other systemic signs include “keratoderma blennorrhagicum” (i.e. papules, vesicles, or pustules on the palms and soles), “circinate balanitis” (non-painful penis rash), sacroiliitis, plantar fasciitis, and Achilles tendonitis. Reactive arthritis can also be associated with life-threatening conditions such as cardiac conduction defects, pericarditis, and aortic insufficiency. In fact, some believe that Christopher Columbus died from cardiac complications from reactive arthritis.

More than 75% of individuals with reactive arthritis are HLA-B27 positive. Interestingly, reactive arthritis is much more common in AIDS patients. The true cause of this increased incidence is currently unknown.

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1
Q

Heerfordt-Waldenstrom

A

Heerfordt-Waldenstrom syndrome is a type of sarcoidosis syndrome characterized by uveitis, parotiditis, fever, and facial nerve palsy.
Other syndrome in sarcoid: Lofgren = legs =triad of erythema nodosum, b/L hilar adenopathy, arthritis

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2
Q

Behcet’s

A

Behcet’s pts typically have more prominent non-ocular manifestations than ocular ones. Systemic manifestations include recurrent oral ulcers (MC sign), epididymitis, skins lesions (e.g. erythema nodosum), CNS involvement, and arthritis, cardiac (myositis). The anterior segment is usually more prominently involved in Behcet’s disease and includes a severe uveitis often with hypopyon formation. Posterior segment signs include widespread occlusive vasculitis, retinal necrosis, ischemic optic neuropathy, and severe vitritis. This disease is associated with HLA-B51. HLA-A29 is associated with birdshot choroidopathy; HLA-DR2 is associated with pars planitis; and HLA-B27 is associated with the various spondylarthropathies (e.g. ankylosing spondylitis).

Morbidity: eyes (2/3), vascular dz (1/3), CNS dz (10-20%).

Corticosteroids - mainstay for initial Rx of acute BD, but most pts eventually become resistant to steroid therapy. Starting dose 1.5 mg/kg/day with gradual taper.
Start immunosuppression with immunomodulating agents: azathioprine, cyclopsorine, infliximab.

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3
Q

Hypopyon with or without fibrin

A

Behcet’s - less likely to have fibrin

HLA B27 - more likely to have fibrin

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4
Q

Subglottic stenosis

A

Wegener’s

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5
Q

Tracheal collapse or h/o tracheostomy

A

polyarteritis nodosa

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6
Q

Phlebitis

A

Sarcoidosis, MS, Birdshot, Eales

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7
Q

Arteritis

A

ARN, PAN, SLE, Susac (retinoscochleocerebral angiopathy)

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8
Q

Both arteritis and phlebitis

A

Behcet and toxoplasmosis

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9
Q

Retinitis: focal vs. multifocal

A 
Focal = toxoplasmosis
Multifocal = HSV/VZV, candidiasis
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10
Q

keratoderma blenorrhagicum

A

“psoriasis” on palms/soles - seen in Reiters

brown aseptic abscesses

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11
Q

rash on palms/soles in adults

A

syphilis (secondary/maculopapular) and Reiters (keratoderma blenorrhagicum)

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12
Q

Photophobia

A

2/2 inflamed iris-ciliary body contracting –> pain 2/2 consensual pupillary response

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13
Q

Myopia and hyeropia in uveitis

A

Myopia from cataract

CME causing hyeropia

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14
Q

Child

A

JIA
toxoplasmosis
toxocariasis
pars planitis

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15
Q

Young adult

A

Anklyosing spondylitis
pars planitis
Fuchs

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16
Q

Adult > 50 yo

A

Birdshot
serpiginuous
masquerade

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17
Q

Male in uveitis

A

most things female (MEWDS, PIC/MCP, JRA)

Male = ankylosing spondylitis, Behcets (but incomplete M = F), PAN.

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18
Q

Nodules in uveitis

A

sarcoidosis, lepropsy, RA

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19
Q

rash on palms/soles in kids

A

Kawasaki

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20
Q

Erythema nodosum

A 
red nodules on lower EXTENSOR surfaces.  Panniculitis - inflammation of subactue fatty tissue.  delayed hypersensitivity
CUBS
Crohns, Coccidomycosis, cat scratch
Ulcerative colitis
Behcet
Sarcoid
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21
Q

livedo reticularis

A 
dilation of capillaries and venules 2/2 blood stasis or vascular changes.  Worse in cold temperatures.
RSPD
PAN
SLE
dermatomyositis
RA
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22
Q

Myalgias

A

PAN

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23
Q

Tendonitis

A

Reiter’s syndrome (Achilles’ tendon)

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24
Q

Arthritis

A 
JRA
Behcet's (but not as big of a feature)
Lyme dz
RA = inflammed synovium 
Reiters  (seronegative arthropathy = inflammed tendon @ insertion; PAIR)
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25
Q

sarcroilitis

A

anklyosing spondylitis, IBD

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26
Q

enthesitis

A

inflammation @ site of ligament or tendon insertion = HLA-B27 assoc/arthropathies

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27
Q

sausage digits/dactylitis =

A

psoriatic arthropathy

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28
Q

sausage digits

A

psoriatic arthritis

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29
Q

Peripheral neuropathy

A

PAN

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30
Q

Headache

A

VKH

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31
Q

Aseptic meningitis

A

Behcet’s

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32
Q

saddle nose deformity

A

syphilis, Wegener’s, relapsing polychondritis

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33
Q

Relapsing polychondritis

A

Inflammed pinna/auricular chondritis (80%)
Abs to collagen (also present in sclera)
episcleritis (40%) and scleritis (15%)
nasal chondritis - saddle nose deformity
vestibular dysfxn

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34
Q

Oral ulcers/aphthous stomatitis

A

Behcet’s and Reieters

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35
Q

SOB

A

Sarcoidosis, Wegener’s, TB?

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36
Q

diarrhea

A

Crohn’s, Whipple dz, ulc colitis

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37
Q

abdominal pain from ischemia

A

PAN

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38
Q

orchitis

A

PAN

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39
Q

Renal problems

A

PAN = protenuria, vascular nephropathy, renal vessel aneurysms
Wegener’s/intersitital nephritis = hematuria, casts
Wegener’s = glomerulonephritis
TINU

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40
Q

Animals

A 
Deer = lyme dz
DUSN - racoons and dogs
pigeons - cryptococcus
mosquitos - wnv
black flies = onchocerciasis
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41
Q

KPs - active vs. inactive

A 
active = creamy white
inactive = pigmented or glassy
comment on shape = stellate KPs in Fuchs, herpes, toxoplasmosi
comment on shape (lower half of cornea)
classically diffuse (limbus to limbus) in fuchs, sarcoid, herpes, CMV
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42
Q

Hypopyon

A

HLA-B27, endophthalmitis, corneal ulcer, Behcet’s, Rifabutin, malingnacy, “silicone oil”

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43
Q

Heterochromia

A

siderosis bulbi (darker iris)
fuchs’
waardernburg’s syndrome = white forelock, broad nasal bridge
congenital horner’s (lighter)

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44
Q

snowball vs snowbank

A 
snowball = cell/proteinaceous debris (sarcoidosis)
snowbank = fibroglial tissue and cells leaking from peripheral phelbitis.   located inferiorly along pars planitis
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45
Q

Swollen ON and retina

A

MCC of swollen ON and retina = CRVO (also think malignant HtN)
cat scratch
DUSN (early)
IRVAN = young healthy (mostly female), retinal arteritis OU with numerous aneurysmal dilations of the retina and ON head arterioles, neuroretinitis, uveitis)
Visual loss 2/2 exudative maculopathy and NV sequelae of retinal ischemia

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46
Q

Focal choroid lesions and vitreous cell

A

Vitreous cells = toxocariasis

No vitreous cell = serpiginous, tumor

47
Q

Multifocal choroidal lesions and vitreous cell

A

Multifocal
vitreous cell = most white dots, VKH, SO
no vitreous cell: OHS, PIC, Krill

48
Q

Panuveitis

A

MC b/L, granulomatous, and NOT idiopathic

Sarcoidosis
Behcets
VKH/SO
syphilis
TB
49
Q

Granulomatous uveitis

A 
sarcoidosis - discrete
TB
VKH/SO - diffuse
syphilis
lens induced uveitis - zonal (phacoanaphylactic)
IOFB
50
Q

Acute uveitis

A 
HLA-B27
Behcet
Lyme
ARN
MEWDS
APMPPE
51
Q

Chronic

A 
JRA
serpiginious
birdshot
pars planitis
intraocular lymphoma
post-usrgical uveitis
sarcoidosis
52
Q

MC uveitis

A

Anterior (usually idopathic) > panuveitis> posterior (usually infectious) > intermediate (usually idiopathic)

53
Q

Anterior uveitis

A 
Idiopathic
HLA-B27
Ankylosing sponydlitis
Reiters
IBD
psoriasis
Fuchs'
JRA
sarcoidosis
54
Q

Intermediate uveitis

A 
pars planitis
Lyme
MS
sarcoidosis
PCNSL
55
Q

posterior uveitis - retinitis causes

A

Focal = toxoplasmosis, cystericercosis

Multifocal = HSV/VZV, syphilis, sarcoidosis, candidiasis

56
Q

posterior uveitis - choroiditis

A

Focal choroiditis

  • vitreous cells: toxocariasis
  • no vitreous cells: serpiginous, tumor

Multifocal choroiditis

  • vitreous cells: white dot cells, VKH/SO
  • no vitreous cells: OHS, PIC, Krill
57
Q

ANCA

A 
c-ANCA = Wegener's,  Cytoplasmic staining, Ab directed to proteinase 3
p-ANCA = perinuclear staining, Ab to myeloperoxidase (MPO), crescentic glomerulonephritis (strong assoc), PAN (moderate assoc), Churg-Strauss (moderate)
58
Q

serology syphilis

A

RPR & VDRL - if positive, indicate active dz. Nml with treatment
FtA-ABS: stay positive for life.

59
Q

Serology lyme

A

Two step test:

1) ELISA or IFA 1st and if positive
2) confirm with western blot/PCR

May be FALSE positive: syphilis, HIV, EBV, RA, SLE

60
Q

Bartonella serology

A

B. henselae Ab in cat scratch or parinaud’s

IgG antibody detection with IFA (indirect fluorescent Ab)

61
Q

Toxoplasmosis

A

negative titers R/O toxoplasmosis, but otherwise not very helpful.

Acute infection indicators: 4 fold increase in IgG titers. Positive IgM or IGA. Titers do not correlate with ocular dz 2/2 low serum levels.

62
Q

HLA

A

Class 1 = on all nucleated cells. HLA A, B, C. antigen presenting platform for CD8 (suppressor T cells).

Class 2 = macrophages/dendritic cells. HLA-DR, -DP, DQ. palfor for CD4 cells

63
Q

HLA -DR4

A

SO/VKH and JRA (also DW2)

64
Q

HLA-B7, -DR2

A

MS/POHS

65
Q

HLA - B44

A

retinal vasculitis

66
Q

Pathergy test

A

Behcets

67
Q

LP

A

syphilis, lyme, VKH

68
Q

CXR

A

TB, sarcoid, thymoma, wegners

69
Q

Gallium or PET scan

A

sacroidosis

70
Q

EKG

A

LHON, Kearn-sayre syndrome, ankylosing spondylitis

71
Q

T lymphocyte modulators

A

cyclosporine (SE HTN): pars planitis, Behcet, VKH

72
Q

Antimetabolites

A

MTX (JRA), mycophenolate

73
Q

Alkylating agents

A

Cyclophosphamide (heme cystitis, sterility). Wegener,s behcets, VKH/SO, relapsing polychondritis

74
Q

Biologic response modifiers

A

Etanercept (?JRA)

Infliximab (Behcet)

75
Q

surgical considerations

A

wait 3 mo of quiescence for CE/IOL and 6 mo for PK

76
Q

Stellate KP

A

Fuchs heterochromic iridocyclitis
herpes
toxoplasmosis

77
Q

fuchs

A

thought to be 2/2 rubella reactivation

78
Q

intermediate uveitis

A

lyme, pars planitis, MS, sarcoid, PCSNL

79
Q

posterior uveitis

A

infection vs. white dot

80
Q

panuveitis

A

sarcoid, behcet’s, VKH/SO, syphilis, TB

81
Q

Ankylosing spondylitis

A

aortic insufficiency, cardiomegaly, conduction defects, colitis, apical fibrosis of the lungs
Eye findings: anterior uveitis, episcleritis, scleritis
Rx: physical therapy and NSAIDS

82
Q

Reiters

A

conjunctivitis, urethritis, arthritis

Assoc/w/: chlamydia, ureaplasma, urealyticum, yersinia, shigella, salmonella

3 major or 2 major + 2 minor
Major: urethritis, polyarthritis, conjunctivitis, keratoderma blenorrhagicum (psoriatic rash on palms/soles)

Minor: plantar fascitis/Achilles tendinitis, circinate balanitis, painless mouth ulcers, prostatitis, cystitis, sacroilitis, tendinitis, recent diarrhea, iritis/keratitis

83
Q

Fuchs

A

develop lighter iris if depigmentation of posterior pigment layer
darker iris if stromal atrophy in blue iridis reveal pigment layer

84
Q

JRA PAUCIarticular

A

RF-, ANA+, pauciarticular/oligoarticular (< 16 yo

late onset - HLA-B27 boys, sudden u/L self-limited duration anterior uveitis

85
Q

JRA - POLYarticular

A

true RA, adolescent females(eyes: dryness/scleritis rarely iritis)

86
Q

Still’s

A

high fever, HSP, adenopathy, leukocytitis, iritis rare

87
Q

Kawasaki

A

< 5 yo
5/6 criteria: fever, b/L conjunctivitis, mild bilateral NONgranulomatous uveitis, rash, cervical adenopathy, oral lesions (fissures, strawberry tongue), lesions of extremities (redness of palms/soles)

Rx: aspirin, IVIG,
systemic steroids CONTRAINDICATED 2/2 risk of coronary artery aneurysm.

88
Q

phacoantigenic glaucoma

A

acute penetration lens injury. Granulomatous rxn (type 3) s/p latent period rexposure to lens protein through surgery or trauma
uveitis with HYPOTONY initially. Later 2ndary glaucoma may develop.
Histology: PMNS at site of ruptured capsule surrounded by epitheloid and multinucleated giant cells

89
Q

pars planitis

A

75% bilateral, 90% of intermediate uveitis, 25% of uveitis in kids,
We are about pars planitis 2/2 CME
HLA-DR15, MS
mild flare with few KPs, anterior vitritis, peripheral retinal periphelbitis, hyperemic disc, no synchiae.

Px: usually burns out in 5-15 years

90
Q

Lyme dz

A

Borrelia burgdorfei 2/2 tick (Ixodes dammini in eastern USA or Ixodes pacificus western US)

Lyme = MC vector borne dz in USA

Dx test: lyme titer, IFA or ELISA followed by western blot
Rx: tetracycline, erythromycin or pencillin

For neuro-ophthalmic lyme disease IV: ceftriaxone or penicillin

91
Q

Lyme stage 1

A

Stage 1: during 1st month erythema migrans, FOLLICULAR CONJUNCTIVITIS, fever, malaise, myalgia

92
Q

Lyme stage 2

A

1-4 mo s/p infection with following manifestations.

NEED TO GET AN LP IF YOU ARE THINKING YOU ARE LOOKING AT STAGE 2

Lyme uveitis = CNS involvement; LP

ocular - keratitis, iritis (GRANULOMATOUS), intermediate uveitis, vitritis, optic neuritis, panophthalmitis
neurological: 30-40% patients, 7th NP, encephaltiis, meningitis

MSK - arthritis, tendonitis, joint effusions

93
Q

Lyme stage 3

A

over 5 months - keratitis, atrophic skin changes, chronic arthritis, adult respiratory distress syndrome, neuropsych

94
Q

Toxoplasmosis

A

oocyst (soil form)
tachyzoite (active infectious form)
bradyzoite (latent form) - thousands of them in a cyst

Rx:
triple therapy: pyrimethamine + sulfadiazine + prednisone + folinic acid (? + clinda)
Bactrim DS + prednisone
?chronic bactrim DS for suppression

95
Q

Toxocariasis

A

2/2 ingestion of contaminated soil

o. Ocular larva migrans: u/L solitary lesion does not complete life cycle (worm not in stool)

1) Endophthalmitis form - lots of inflammation
2) posterior granuloma form = organism encased in tissue in back of eye. does best b/c encased in the back of the eye. Can’t cause RD or generate a lot of inflammation
3) Granuloma off to the side - classic strand that goes to posterior pole/ON

o. Visceral larva migrans, fever, LA, HSP, pneumonitis, eosinophili, no ocular inv

Dx: can do AC tap for eosinophils, ELISA for toxocara Ab titers from blood or AC

Rx: topical steroids and cycloplegics, PPV for RD. Thiabendazole for systemic toxocariasis but may make ocular dz worse.

96
Q

POHS

A

yeast (yeast form is which causes dz/problem) and filamentous fungi
eastern/midwestern USA with N. european descent
HLA-B7, DR2
Triad: PPA, multiple punched out CR, CNV. NO VITRITIS

97
Q

N. european descent

A

Birdshot, PXE, POHS

98
Q

CMV

A

CD4 < 50

Different types: frosted branch, brush border, HIV retinopathy, cheese pizza

99
Q

ARN

A

usually incompetent, 2/3 u/L
PAINFUL, mutton fat KP, likes arteries, mild iritis, pale disc edema, within 2 mo the necrotic retina sloughs, salt/pepper pigmentation

Rx: acyclovir IV, ganciclovir, corticosteroids, ASA
watch other eye, may develop ARN within 4 weeks
75% develop RD

100
Q

PORN

A

ARN in AIDS, painless with minimal intraocular inflammation
multiple discrete peripheral or central areas of retinal opacification
vasculitis not prominent
Poor Px, 2/3 NLP
Rx: foscarnet + ganciclovir

101
Q

subacute sclerosing panencephalitis

A

rare wild-type measles. Usually unvaccinated kids 8 year s/p primary infection
Si/Sx: nonspecific maculopathy, focal retinitis, disc swelling, minimal vitritis
Systemic findings: personality change, seizures, dementia, death

eye findings may precede neuro findings by weeks to years.

No Rx

102
Q

Candidiasis

A

10% endophthalmitis from candidemia
Si/Sx: anterior uveitis, retinal hemorrhage, perivascular heathing, chorioretinitis with fluffy white lesions, vitreous abscess, subretinal abscess

Rx: amphotericin B (intravenous or intravitreal), fluconazole, voriconazole

103
Q

pneumocystitis choroiditis

A

people with HIV/AIDS used to get this if they weren’t on bactrim

104
Q

cysticercosis

A

taneia solium or saginata
“balloon in eye” = intravitreal (encapsulated worm)
harder to ID if subretinal

PPV Rx

105
Q

Leprosy

A

mycobacterium leprae

likes COLD areas: skin, nerves, nasal mucosa, eyes

keratitis, scleritis, GRANULOMATOUS iridocyclitis, hypotony, phthisis, many others

Rx: dapsone, rifampin

106
Q

TB

A

likes highly oxygenated areas (apex of lungs), choroid = multifocal choroiditis

107
Q

Rx with dapsone

A

Leprosy, relapsing polychondritis, OCP, brown recluse spider bites

108
Q

DUSN

A

dog hookworm (ancylostoma caninum) and raccoon (Baylisascaris procynosis)

Diffuse u/L subacute neuroretintiis/u/L wipe out syndrome

1st phase = postequatorial multiple evanescent grayish white dots with vitritis, retinal vasculitis

2nd phase: ON atrophy, extensive pigment dispersion, arteriolar atttenuation (look like RP)

109
Q

Onchocerciasis

A

2nd MCC blindness in Africa
Blackfly vector and intermediate host
sub-cutaneous nodules
dead microfilariae cause AC rxn

Si/Sx: microfilaria swimming in AC, keratitis, iridocyclitis, chorioretinitis, RPE dispersion, CR atrophy, ON atrophy

Rx: ivermectin (macrolytic lactone) - single PO dose of 150 ug/kg, repeated annualy x 10 years

110
Q

Whipple’s dz

A

Tropheryma whippelii

malabs, diarrhea, migratory polyarthritis

neuro-ophtho: nerve palsy, ophthalmoplegia, nystagmus
rarely: anterior uveitis, vitritis

Rx: bactrim possibly for 1 year

111
Q

P. acnes

A

ANAEROBIC gram positive rod
sequered in capsular bag s/p cataract surgery
chronic GRANULOMATOUS uveitis with fibrin/hypopyon
Rx: intravitreal vanc and cephalosporin + IOL and capsule removal.

112
Q

Ophthalmomyiasis

A

ocular invasion of fly larvae into AC, posterior segment, or subretinal (tracks of atrophied RPE)
death of organism causes inflammation

113
Q

granulomatous uveitis,

A

including syphilis, Lyme disease, tuberculosis, Behcet’s disease, VKH/SO

114
Q

CNV MC in which white dot syndrome?

A

A: MCP

MEWDS is an acute onset syndrome characterized by multiple, small gray-white dots at the level of the deep retina and RPE in the posterior pole. In some patients, a transient foveal granularity develops that is pathognomonic of this condition. Patients typically present with a unilateral decrease in vision (80%). It is more common in women in the second to fifth decades. Treatment is unnecessary as the fundus exam and vision typically improves spontaneous over 2-6 weeks. Rarely patients can have persistent visual field defects. CNV does not occur.

Multifocal choroiditis and panuveitis syndrome is a bilateral disease that predominantly affects women between the second and sixth decades. Patients present with bilateral vitritis, disruption of the peripapillary RPE and multifocal choroiditis. The multiple yellow choroidal lesions later evolve into chorioretinal scars similar to “histo spots.” Presenting symptoms include floaters, decreased vision, photopsia and visual field defects (e.g., enlarged blind spot). CNV occurs in approximately 20% of affected eyes and is the leading cause of vision loss in these patients. Local or systemic corticosteroids and/or immunomodulating agents are usually necessary to control inflammation after infectious etiologies are ruled out. CNV is treated with anti-VEGF therapy.

Birdshot retinochoroidopathy (vitiliginous chorioretinitis) is characterized by vitritis (100%), variable degrees of disc edema, vascular sheathing, and characteristic yellow, ovoid, “birdshot” chorioretinal lesions that are most numerous in the nasal retina. Patients present with floaters, blurred vision and peripheral photopsia. Vision loss is most commonly the result of cystoid macular edema (CME) in up to 30% of patients. CNV can occur but is rare. HLA-A29 is positive in 90% of patients. Immunomodulation is frequently needed.

Serpiginous choroidopathy is a recurrent inflammatory disease of the choroid that causes a serpiginous (pseudopodial) or geographic pattern of scarring in the posterior fundus. Acute lesions have a geographic zone of gray-yellow discoloration of the RPE which spreads from the disc. These areas then become atrophic over weeks to months and new lesions can occur elsewhere or contiguous with the areas of atrophy. The fellow eye may become involved months or years later. Dense scotomata corresponding to the involved areas develop. CNV occurs only rarely at the margin of an area of chorioretinal atrophy.

Note: CNV development is also very common in punctate inner choroiditis (PIC), with an incidence of up to 30% in areas of chorioretinal scarring.

Uveitis (3 decks)

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