A 29-year-old male was referred to Infectious Disease Clinic of Hamadan Sina Hospital in summer 2008 with acute onset of fever, headache, malaise, sweating and low back pain. On examination, the patient was conscious and his temperature was 39 C. There were no obvious systemic findings such as organomegaly on physical examination. Laboratory test findings were: white blood cell (WBC) count of 13350 (Neutrophil: 85%), erythrocyte sedimentation rate (ESR) 48m/h, CRP+, RF-, ANA-, Wright's agglutination titer of 1/1280. Results of serologic testing for syphilis, hepatitis, tuberculosis and AIDS were negative. Outcomes of a lumbar puncture were normal. Blood levels, for sugar, sodium and potassium were normal. Blood cultures were negative and electrocardiogram and chest-X-ray (CXR) were normal. The patient was diagnosed with brucellosis, and treated with rifampin 600 mg/day and doxycycline 100 mg/twice daily.
After a week, the patient was referred for an Ophthalmology consult with complaints of ocular pain and redness and visual complaints. On ophthalmic examination, visual acuity in both eyes was 20/25. There was diffuse conjunctival injection bilaterally which was more prominent in the right eye. The conjunctional injection was a mixture of ciliary injection, episcleritis and conjunctivitis but more severe in the ciliary area. Neither eye had signs of intraocular inflammation. Pupillary light reflexes were sluggish bilaterally but no afferent pupillary defect was present. The patient was orthophoric without any muscle involvement and there was no diplopia. On funduscopy, there was bilateral optic disc swelling along with retinal hyperemia (optic disc hyperemia and vascular tortuosity) and diffuse intraretinal hemorrhage [Figure 1]. Intraocular pressure (IOP) was 26 mmHg in the right eye and 24 mmHg in the left eye. The patient was hospitalized with a probable diagnosis of ocular brucellosis and was treated with co-trimoxazole adult two tablets, three times a day (tid), rifampin 600 mg/day doxycycline 100 mg/BID and prednisolone 1 mg/kg for 2 months. Computed tomography and magnetic resonance imaging studies of the brain and optic nerve were requested. Both studies were unremarkable. A brief visual field limitation was reported on perimetry. Fever and headache diminished within 48 hours of the treatment however, ophthalmic complaints lingered. One week after treatment, visual acuity improved to 20/20. Conjunctival hyperemia had decreased but previous funduscopic findings remained unchanged. IOP was 19 mmHg OD and 16 mmHg OS using timolol. Four weeks after treatment, there were no visual complaints. Optic disc swelling and hyperemia had decreased and IOP bilaterally was within normal limits. Thirteen months after treatment, the funduscopic examination was normal [Figure 2].