History

Medical History

TB diagnosed 2 years ago and confirmed by bronchoscopy with acid fast bacillus seen on BAL. ROS was noncontributory. Specifically, the patient denied any history of mouth or genital ulcers and No skin rashes.

Medications

• Rifabutin
• Ethambuto
• Augmentin
• Biaxin

Examination

• Vision: OD: LP, OS: 20/20
• Pupils: Not visualized OD, Round and reactive OS.
• Motility: Full OU
• Intraocular pressures: Normal OU
• Slit lamp examination: See photographs for OD The conjunctiva was injected. The sclera was intact. The cornea was clear with no lacerations. The anterior chamber had a large round whitish fibrin material. There was also a 1mm hypopyon noted. OS was within normal limits
• Fundus Examination:
• OD: No view to the fundus nerve in both
• OS: Within normal limits

Differential Diagnosis

• HLA B-27 related uveitis including: Reiter’s syndrome, inflammatory bowel disease, ankylosing spondylitis, postinfectious or reactive arthritis and psoriasis.



• Infectious endophthalmitis: usually postoperative, but may be indogenous in patients with compromised immune system



• Behçet’s disease: usually associated with other systemic sings such as mouth ulcers and skin lesions. Major and minor criteria exist for diagnosing this condition



• Syphilis: can present acutely with severe anterior segment inflammation resulting in a hypopyon



• Medication: Rifabutinâ has been reported to cause severe hypopyon related AC reaction in HIV positive patients receiving the medicine as a prophylaxis against atypical mycobacterium.



• Lymphoma and leukemia can present with hypopyon but other sings and symptoms will be also present.



• Retinoblastoma in children can rarely present with a hypopyon if vitreous seeding is present.



• Rupture of the anterior lens capsule usually results in protrusion of cortical material into the AC along with high IOP.

Laboratory Work-up

• CBC/diff: Normal
• ANA: <40
• VDRL: Nonreactive
• MH-ATP: Nonreactive
• Lyme titer: Negative
• ACE: 72 (range 9-67)
• Lysosyme 12 (range 4-13)
• HLA-B27 Negative
• HIV Negative
• Chest X-ray: Old calcified granuloma in the left apex. No acute dz.

Diagnosis

Rifabutinâ associated uveitis

Rifabutin is a semi-synthetic antimycobacterial agent mainly used for treatment of atypical Mycobacterium infection associated with AIDS. The association between Rifabutin and acute hypopyon-associated anterior uveitis is well reported. The incidence is usually higher if the patient is also taking Clarithromycin or Fluconazole since the all these medications compete for the cytochrome p-450 pathway. The mechanism of uveitis is poorly understood. The hypopyon is usually unilateral in 60-70% of the cases but could present with mild contralateral uveitis. The treatment is to discontinue the use of Rifabutin and start frequent topical steroids. Patient usually respond promptly to this treatment. Other conditions on the differential diagnosis list should also be considered and worked up. Rifabutin use has also been reported to be associated with cystoid macular edema.