Uveitis Flashcards
% patients with primary CNS lymphoma who have ocular involvement
25%
% patients with primary intraocular lymphoma who will develop CNS disease within 2 years of diagnosis
50-67%
% patients with PCNSL who have CSF seeding
30-40%
Triple therapy for toxo
- Pyrimethamine (loading 50-100 mg, treatment 25-50 mg daily)
- Sulfadiazine (1g QID)
- Prednisone (0.5-1 mg/kg/day depending on severity of inflammation)
+Folinic acid (15 mg daily) to prevent myelosuppression while on pyrimethamine!
What needs to be monitored while patients are on triple therapy?
CBC (leukopenia and thrombocytopenia due to myelosuppression)
Alternatives to triple therapy for toxo
Bactrim, azithromycin, clindamycin (if sulfa allergy)
For pregnant patients, can use atovaquone (750 mg QID), sulfonamides (first 2 trimesters), or local injections (clindamycin and dexamethasone)
Lymphocytic choriomeningitis virus presents most similarly to what other infection?
Toxoplasmosis (differentiated by diffuse nature of intracerebral calcifications in toxo, vs periventricular in LCMV)
Organism that causes ocular larval migrans?
Toxocara canis or cati (tissue invasion by second-stage larvae)
Diagnosis for seizures, chorioretinal scars, intracranial calcifications in area with mouse droppings
Lymphocytic choriomeningitis virus
Major risk factor for the development of primary CNS lymphoma and primary intraocular lymphoma
Immunosuppression
Introducing HAART in patients with CMV and AIDS reduces incidence of CMV retinitis and associated complications by ___%.
Introducing HAART in patients with CMV and AIDS reduces incidence of CMV retinitis and associated complications by 80%.
Diagnosis for patient from Mexico with uveitis, seizures, and CNS calcifications
Acquired cysticercosis
Mechanism of inflammation in autoimmune regulator-deficient mice
Lack transcription factor used by thymus to develop T-cell self-tolerance -> T-cells that are autoreactive to retinal photoreceptor proteins cause posterior uveitis
What condition mimics human T-lymphotropic virus type 1 uveitis?
Adult T-cell leukemia/lymphoma
Mechanism of action of methotrexate
Folic acid analogue and inhibitor of dihydrofolate reductase, which inhibits DNA replication, but anti-inflammatory effects result from extracellular release of adenosine
Differential for intermediate uveitis
Pars planets, sarcoidosis, syphilis, toxocariasis, Lyme disease, multiple sclerosis, tuberculosis
Diagnosis for anterior uveitis with papular skin lesions, conjunctival nodules, RPE atrophy, optic atrophy
Onchocerciasis (Central America, South America, sub-Saharan Africa)
Transmitted by black flies -> larvae mature into worms that migrate to skin and form subcutaneous nodules
Treat with ivermectin
What further testing is required in patient with nongranulomatous anterior uveitis with hypopyon and HLA-B27+ ankylosing spondylitis?
CXR, TTE (risk of pulmonary apical fibrosis and cardiovascular disease due to aortic insufficiency)
Differentiate between c-ANCA and p-ANCA
c-ANCA: cytoplasmic immunofluorescence pattern, antibodies to proteinase 3, associated with GPA
p-ANCA: perinuclear immunofluorescence pattern, antibodies to myeloperoxidase, associated with PAN, microscopic polyangiitis, Churg-Strauss
Differentiate between ARN and CMV retinitis
ARN has more profound vitritis, progresses more rapidly, demonstrates less hemorrhage
Side effects of cyclosporine
Gingival hyperplasia, paresthesia, GI upset, fatigue, hypertrichosis, hypertension, renal dysfunction, hirsutism
Side effects of cyclophosphamide
Leukopenia, hemorrhagic cystitis, sterility, reversible alopecia
What condition has cyclosporine proven effective in controlled studies for?
Behcet disease-related uveitis
Mechanism of cyclosporine
calcineurin inhibitor that eliminates T-cell receptor signal transduction, down-regulates interleukin-2 (IL-2) gene transcription and receptor expression of CD4+ T-lymphocytes
In contrast to other white dot syndromes, what is absent in PIC?
Vitritis
Why might a patient with acute leptospirosis have resolution of systemic symptoms but continuing uveitis?
The eye and brain are immunologically privileged sites (symptoms may persist longer in immunologically privileged sites).
What is the earliest and most common sign of ocular leptospirosis?
Circumcorneal conjunctival hyperemia
What is the most common presentation of uveitis caused by tuberculosis?
Disseminated choroiditis
What supplement interferes with prescribing oral doxycycline, rifampin, and high-dose prednisone to patient for disseminated bartonellosis and neuroretinitis?
Calcium (administer 2 hours before or after tetracycline administration because medications mutually prevent each other’s GI absorption)
Side effects of tetracyclines
Potentiate blood thinners (-> bleeding diathesis), teeth discoloration in young, photosensitivity, decrease efficacy of birth control medication, interferes with GI absorption of calcium
What animal model of uveitis most closely resembles VKH syndrome in humans?
Experimental autoimmune uveoretinitis (panuveitis)
Animal models that cause:
- Anterior uveitis
- Posterior uveitis
- Panuveitis
Anterior: equine recurrent uveitis, endotoxin-induced (or experimental immune) uveitis (transient anterior uveitis)
Posterior: autoimmune regulator deficient mice
Panuveitis: experimental autoimmune uveoretinitis
Compare and contrast MHC class I molecule structure from MHC class II
Similar: heterodimers made of alpha and beta chains, alpha units encoded by MHC gene
Different: MHC class II beta units encoded by MHC gene, MHC class I beta unit is constant (beta-2-microglobulin)
Most common findings for primary vitreoretinal lymphoma
Creamy yellow/white subretinal and sub-RPE infiltrates and vitritis
Mechanism of cyclophosphamide
Alkylating agent that permanently crosslinks DNA
Mechanism of azathioprine
Purine nucleoside analogue that interferes with DNA replication and transcription
Mechanism of mycophenolate mofetil
Inhibits inosine monophosphate dehydrogenase and DNA replication
Diagnosis of parotitis, fever, facial nerve palsy, and uveitis
Sarcoidosis (Heerfordt syndrome or uveoparotid fever)
What is Lofgren syndrome?
Erythema nodosum, febrile arthropathy, bilateral hilar adenopathy, and acute uveitis
What medication is associated with scleritis?
Pamidronate
Name for antigenic sites on antibodies
Idiotopes
HLA association for tubulointerstitial nephritis and uveitis
HLA-DRB1*0102
What virus or virus family is most often implicated in glaucomatocyclitic crisis?
Herpesvirus (CMV)
Most common ocular manifestation associated with inflammatory bowel disease
Anterior uveitis
Presentation and transmission of chikungunya viral uveitis
Anterior uveitis and retinitis; ssRNA alpha virus transmitted by infected mosquitos
What is suggested by anterior chamber cells that move very slowly?
Fibrinous inflammation from platelet degranulation
In what stage does Lyme uveitis occur most commonly?
Stage 2, disseminated disease
Most commonly intermediate uveitis
Typical presentation of serpiginous choroiditis
Sudden onset of central or paracentral scotoma
What receptor is strongly involved in lipopolysaccharide-induced uveitis?
Toll-like receptor 2 on macrophages
Most likely causative organism in postoperative hypopyon, corneal infiltrate, iris mass, necrotizing scleritis, vitreous snowballs
Fungus
__% of all blindness in the US attributed to inadequately treated uveitis.
10% of all blindness in the US attributed to inadequately treated uveitis.
HLA association with Behcet disease
HLA-B51
Appearance of fungi on stains:
- Aspergillus
- Cryptococcus
- Candida
Aspergillus: septate, dichotomously branching hyphae
Cryptococcus: round capsules with a halo (India ink)
Candida: budding yeast with pseudohyphae appearance
How do patients with Whipple disease present? How is this diagnosed?
Panuveitis or retinal vasculitis in patients with abdominal pain, diarrhea, steatorrhea, weight loss, neurologic dysfunction
Duodenal biopsy demonstrating PAS+ bacillus in macrophages within intestinal villi
Most common autofluorescence pattern in patient with multifocal choroiditis
Multiple punctate hypoAF spots more numerous than clinical appearance
Autofluorescence pattern in patient with AZOOR
Central hypoAF with peripheral hyperAF
Autofluorescence pattern in patient with APMPPE
HyperAF corresponding to areas of blockage on FA
What regulates anterior chamber associated immune deviation?
TGF-beta, vasoactive intestinal peptide
Interferon gamma causes ___ and macrophage infiltration.
Interferon gamma causes neutrophil and macrophage infiltration.
Substance P plays a role in vascular permeability and causes ___ infiltration.
Substance P plays a role in vascular permeability and causes leukocyte infiltration.
Tumor necrosis factor-alpha is involved in ___ cell infiltration.
Tumor necrosis factor-alpha is involved in mononuclear cell infiltration.
> 5mm induration from PPD test considered positive in what populations?
Exposure to active TB, HIV, or radiographic evidence of healed TB lesions
> 10mm induration from PPD test considered positive in what populations?
DM, renal failure, systemic IMT, immigrants from TB-endemic areas, health care workers
Most common ocular manifestation of human T-cell lymphotropic virus 1 infection?
Intermediate uveitis
For how long does fluocinolone implant release therapeutic levels of corticosteroids to vitreous cavity?
30 months
Causes of chronic indolent postoperative inflammation
Propionibacterium acnes, Candida parapsilosis
Hypersensitivty reaction in atopic keratoconjunctivitis? AKC-related dermatitis?
AKC: type IV (mast cell stabilizers are therefore less effective in these patients)
Dermatitis: type I
Treatment for human T-lymphotropic virus type-1 associated retinal vasculitis?
Systemic corticosteroids
What finding in VKH disease suggests chronicity?
Choroidal depigmentation, or sunset glow fundus
