it is frequently used in immunocompromised patients with human immunodeficiency virus ( hiv ) or a history of organ or stem cell transplantation .
anterior uveitis and hypopyon are well - recognized and frequently reported complications of rifabutin treatment ; however , posterior involvement is relatively rare [ 1 , 2 ] . here , we describe a case of rifabutin - associated panuveitis in a young patient with a history of acute myeloid leukemia .
a 17-year - old eritrean girl presented with a 5-day history of redness , tearing , and photophobia which started in her right eye ( od ) and then involved her left ( os ) .
she recalled similar , but less severe symptoms over the 2  months prior to presentation .
she was treated with chemotherapy and received an allogeneic hematopoietic stem cell transplant 6  months after diagnosis .
she developed graft - versus - host - disease ( gvhd ) of the gastrointestinal tract , lungs , and skin with mild ocular surface involvement , but these issues were stable at the time of presentation to the eye clinic .
on initial examination , pinhole visual acuity was 20/32 in each eye ( ou ) , and intraocular pressures were 14  mmhg ou .
the anterior chambers had 3 + and 4 + cells ( od and os , respectively ) , and bilateral moderate vitritis was noted .
the left eye also had a hypopyon ( less than 1  mm ) and posterior synechiae of the iris ( fig .  1 ) .
both eyes were treated with topical prednisolone acetate 1% every hour and cyclopentolate twice daily . due to the concern for recurrent leukemia or infection
, aqueous humor was obtained from the left eye ; cytology was negative for malignant cells , and cultures were negative .
laboratory testing was negative or within normal limits for rpr , syphilis igg , hepatitis b and c , angiotensin - converting enzyme , lysozyme , ana , anti - dsdna , rheumatoid factor , and hla - b27 .
1anterior segment photograph of the left eye showing a small hypopyon and visible vitreous debris ( posterior synechiae were broken by dilation ) anterior segment photograph of the left eye showing a small hypopyon and visible vitreous debris ( posterior synechiae were broken by dilation ) topical corticosteroids were tapered to every 2  hours ou .
ten days later , the patient developed recurrent bilateral anterior uveitis and vitritis with a hypopyon os .
fluorescein angiography ( fa ) showed diffuse retinal vascular leakage and late staining of the optic nerves in both eyes ( fig . 
a more detailed review of her medications and medical history revealed she was on rifabutin for recurrent mac .
nearly 2  years before she developed uveitis , she had completed a 9-month course of ethambutol , clarithromycin , and rifabutin for mac cultured from a lung biopsy . during the same period , she was on systemic immunosuppressive medications ( mycophenolate mofetil , cyclosporine , and prednisone ) for gvhd .
eight months before presenting with hypopyon uveitis , ethambutol , clarithromycin , and rifabutin were restarted for recurrent mac .
rifabutin dosing was twice as high ( 300  mg every monday , wednesday , and friday ) , and she was no longer on systemic immunosuppressive agents .
after rifabutin - associated uveitis was diagnosed , her medication was switched from rifabutin to moxifloxacin .
topical corticosteroids were continued at the same frequency ( every 2  hours ) , and the hypopyon resolved 5  days later . in the first 2  weeks of follow - up , the macular edema initially worsened , os > od , but over time , the thickening gradually returned to normal ( fig .  3 ) .
on fluorescein angiography , the diffuse retinal leakage had improved at 5  weeks and had resolved after 4  months on a slow topical corticosteroid taper ( fig . 
2fluorescein angiography montages of the right and left eyes : a , b baseline ( prior to discontinuation of rifabutin ) .
3cirrus oct of the left eye : cystoid macular edema present 9  days ( a ) after stopping rifabutin that resolved 1  month later ( b ) fluorescein angiography montages of the right and left eyes : a , b baseline ( prior to discontinuation of rifabutin ) .
e , f four months after stopping rifabutin cirrus oct of the left eye : cystoid macular edema present 9  days ( a ) after stopping rifabutin that resolved 1  month later ( b )
anterior uveitis and hypopyon are the most frequent manifestations of rifabutin - associated uveitis ; however , severe cases may develop dense vitritis with large yellow - white opacities or panuveitis resembling endophthalmitis [ 3 , 4 ] . despite the strong association with rifabutin ,
infectious , autoimmune and neoplastic etiologies should still be investigated depending on the clinical situation .
examination of aqueous humor and/or vitreous via culture , cytology , or polymerase chain reaction can help rule out infection or malignancy .
although mild to moderate vitritis frequently develops in rifabutin - associated uveitis , posterior involvement is less frequent [ 57 ] .
similar to the previous cases , our patient presented with uveitis several months after the start of rifabutin and responded quickly to topical corticosteroids and discontinuation of rifabutin .
of the four cases described by skolik , only one patient had diffuse vasculitis on fa ; the others had mild peripheral vasculitis or perivascular sheathing .
of note , the patient with diffuse fa changes was immunocompetent , whereas the other patients had acquired immunodeficiency disease syndrome ( aids ) and cd4 counts less than 100 cells / mm .
in each of the single case reports by arevalo and vaudaux , the rifabutin - associated uveitis was unilateral and the posterior findings were focal .
arevalo s patient had aids and a cd4 count of 3 cells / mm ; a focal area of sclerosed retinal vessels was noted after intraocular injections of vancomycin and gentamicin for presumed endophthalmitis . in the case from vaudaux ,
the patient had been treated with systemic prednisone for chronic obstructive pulmonary disease 4  months prior to developing uveitis , but was otherwise immunocompetent .
the fa and ocular coherence tomography ( oct ) confirmed unilateral cystoid macular edema . in our immunocompetent patient ,
the vasculitis was notable for its diffuse and bilateral nature and slow resolution after the discontinuation of rifabutin .
rifabutin - associated uveitis was initially described in hiv - positive patients , but it may also occur in patients who are immunocompetent . only a few pediatric cases have been reported ; however , due to the possible association with low body weight , weight - based dosing has been suggested as a strategy to prevent uveitic complications .
our patient weighed 42.5  kg , and uveitis developed after the rifabutin was restarted at twice the initial dose .
it is unclear whether the lack of systemic immunomodulatory medications influenced the onset of uveitis during the second course of rifabutin since patients have developed rifabutin uveitis while iatrogenically immunosuppressed after transplantation .
perhaps an intact immune system predisposed our patient to develop more extensive retinal vasculitic changes .
we describe a case of rifabutin - associated hypopyon uveitis in a young immunocompetent patient with an unusual degree of diffuse bilateral retinal vasculitis .
while the anterior chamber and vitreous inflammation disappeared rapidly after discontinuation of rifabutin , resolution of the retinal vasculitis took several months .
fluorescein angiography helped assess the extent and severity of uveitis as well as guide the topical corticosteroid taper .
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 purposethis study reports a case of bilateral rifabutin - associated uveitis in a child with a history of acute myeloid leukemia.methodswe utilized a clinical case description and brief discussion.resultsa 17-year - old girl presented with acute bilateral anterior uveitis , a hypopyon in the left eye , and moderate bilateral vitritis . 
 she had a history of acute myeloid leukemia status post - allogeneic hematopoietic stem cell transplant 5  years earlier . 
 she was receiving rifabutin for a biopsy - proven mycobacterium avium complex pulmonary infection . 
 work up for infectious and neoplastic etiologies was negative . 
 the uveitis initially responded to topical corticosteroids , but recurred when the drops were tapered . 
 fluorescein angiography demonstrated diffuse vasculitis of small retinal vessels and cystoid macular edema . 
 after rifabutin was discontinued , the uveitis and vasculitis slowly resolved.conclusionfluorescein angiography demonstrated widespread retinal vasculitis which is a rare manifestation of rifabutin - associated uveitis . 
Introduction
Case report
Discussion
Conclusion
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