A 63-year-old female was referred from an outside hospital due to bilateral ocular redness and decreasing vision of 5 days' duration with only mild ocular irritation. Review of systems revealed 3 weeks of progressively worsening arthralgias, subjective fevers, and headache. The patient had a history of well-controlled HIV infection although without recent blood work (CD4 count 630 from 6 months prior), latent TB status post treatment, and cirrhosis secondary to non-alcoholic steatohepatitis, all managed by an outside hospital. The patient had been treated for latent TB with rifabutin 300 mg daily for a 4-month treatment course 9 months prior. Rifabutin was chosen for the treatment instead of isoniazid due to the non-alcoholic steatohepatitis. However, due to pharmacy error, the patient was restarted on rifabutin 300 mg daily for 3 months prior to admission while concurrently on Genvoya  (elvitegravir 150 mg - cobicistat 150 mg - emtricitabine 200 mg - tenofovir alafenamide 10 mg) for HIV management which she had started 5 months prior to admission.
Ocular examination revealed a best corrected visual acuity of 20/70 in the right eye and count fingers at 4 feet in the left eye. Intraocular pressure was within normal limits in both eyes. Pupils were reactive in both eyes without relative afferent pupillary defect, and extraocular movements showed no limitations. Anterior segment examination was significant for 2+ injection of the conjunctiva in both eyes and a <1 mm hypopyon with 4+ anterior chamber cell and flare with fibrin attached to the anterior lens capsule in both eyes. Posterior examination showed 4+ anterior and posterior vitritis with only a limited view of the inferior retina showing several opaque white vitreous opacities in the right eye.
Due to the uncertain immunosuppressive state on presentation as well as systemic complaints, an extensive infectious work-up was performed in an inpatient setting in concert with the Infectious Diseases Service. Serum syphilis enzyme immunoantibody, rapid plasma reagin, Borrelia burgdorferi antibody, CMV IgG/IgM, varicella IgG, and HSV type 1/2 IgM were negative. Quantiferon-TB was positive and chest CT showed no evidence of intrathoracic TB. Serum angiotensin-converting enzyme, C-reactive protein, and erythrocyte sedimentation rate were within normal limits. CT head and lumbar puncture showed no evidence of neurological involvement. A vitreous sample was obtained from the left eye. Gram stain showed polymorphonucleated white blood cells without organisms and cultures showed no growth. The encephalitis panel polymerase chain reaction was administered to the vitreous tap sample and was negative; this included: enterovirus, HSV type 1/2, herpesvirus 6, parechovirus, varicella zoster, Cryptococcus neoformans/gattii, Escherichia coli K1, Haemophilus influenzae, Listeria monocytogenes, Neisseria meningitidis, Streptococcus agalactiae, Streptococcus pneumoniae, and cytomegalovirus. On day 1 of hospitalization, vision had worsened to count fingers and hand motion at near without correction (sc) although without development of significant ocular discomfort.
Due to the high suspicion for a non-infectious etiology, the patient was initially treated with cycloplegia and topical prednisolone with discontinuation of rifabutin, and vision and inflammation improved after 3 days, without other treatment; visual acuity on hospital day 3 was sc 20/400 and count fingers at near with cycloplegia. After infectious work-up had been negative, the patient was started on intravenous methylprednisolone 250 mg q.i.d. for 1 day and transitioned to oral prednisone at discharge, 60 mg daily with weekly taper. At 10-day follow-up the patient's arthralgias had resolved, her visual acuity was cc 20/200 and 20/400 at distance with resolving anterior segment inflammation and persistent vitritis (Fig. 1a, b). At 3-month follow-up her visual acuity was cc 20/40 and 20/40 at distance with mild residual vitritis (Fig. 1c, d).