Year : 2000 | Volume
: 48 | Issue : 4 | Page : 311--2
Acute panuveitis with haemorrhagic hypopyon as a presenting feature of Acquired Immunodeficiency Syndrome (AIDS)
J Biswas, TK Samanta, HN Madhavan, N Kumarasamy, S Solomon
Medical Research Foundation, Chennai, India
Medical Research Foundation, Chennai
|How to cite this article:|
Biswas J, Samanta T K, Madhavan H N, Kumarasamy N, Solomon S. Acute panuveitis with haemorrhagic hypopyon as a presenting feature of Acquired Immunodeficiency Syndrome (AIDS).Indian J Ophthalmol 2000;48:311-2
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Biswas J, Samanta T K, Madhavan H N, Kumarasamy N, Solomon S. Acute panuveitis with haemorrhagic hypopyon as a presenting feature of Acquired Immunodeficiency Syndrome (AIDS). Indian J Ophthalmol [serial online] 2000 [cited 2020 Mar 29 ];48:311-2
Available from: http://www.ijo.in/text.asp?2000/48/4/311/14837
Anterior uveitis is a known clinical entity in herpes zoster ophthalmicus associated with AIDS. However, reports of acute haemorrhagic hypopyon uveitis in such cases are lacking. Herein we describe a young male patient presenting with acute panuveitis with haemorrhagic hypopyon, who was found HIV positive on investigation.
Indian J Ophthalmol 2000;48:311-12
Acquired Immunodeficiency Syndrome (AIDS) is fast becoming a disease of immense epidemic potential in India. Patients with HIV infection carry a 52-100% lifetime cumulative risk of developing at least one ocular complication. We have earlier reported the first two cases of ocular lesions in AIDS in India, as well as a series of 70 such cases. Anterior uveitis in AIDS can occur in association with herpes zoster ophthalmicus (HZO), as a spillover of cytomegalovirus (CMV) retinitis or as rifabutin-associated uveitis. Features of HZO in HIV-positive patients may include severe and enduring cutaneous lesions, epithelial and stromal keratitis, and anterior uveitis. A strong clinical suspicion is needed, however, to rule out HIV infection in such cases. We report a case of a 25-year-old male who presented with acute haemorrhagic hypopyon uveitis. Subsequently, an anterior chamber (AC) tap revealed Varicella zoster virus (VZV) by direct immunofluorescence study. The patient was found HIV positive on investigation.
A 25-year-old male presented with pain, redness, watering and photophobia in the left eye and perichondritis in the left ear for 20 days. On examination, his best-corrected visual acuity was 6/6, N6 in the right eye and 6/60, N36 in the left eye. Extraocular movements in both eyes were full and painless. On slitlamp examination, the right eye was normal. In the left eye, he had marked circumciliary congestion, corneal oedema, mutton fat keratic precipitates, atrophic patches in iris, rubeosis iridis and uveal pigments on the anterior surface of the lens. There was 2+ aqueous flare, 3+ aqueous cells, haemorrhagic 2mm mobile hypopyon [Figure:1], 2+ vitreous flare, and 2+ vitreous cells. Applanation pressure was 12 mm Hg in the right and 30 mm Hg in the left eye. Fundus examination of the right eye was normal; the left eye showed one disc area of retinal haemorrhage inferior to the macula, with a surrounding zone of ischaemia, through the hazy media. A clinical diagnosis of infective uveitis was made and due to presence of haemorrhagic hypopyon, viral uveitis was strongly suspected.
The AC tap obtained under topical anaesthesia with proper aseptic precaution was studied using direct immunofluorescence with monoclonal antibodies against CMV and polyclonal antisera against herpes simplex virus (HSV) and VZV, as earlier described by us. VZV antigen was found in the cells in aqueous aspirate [Figure:2]. The ELISA (Tridot & Immunocomb method) for anti HIV 1 and 2 antibodies and Western blot test for HIV were positive. Systemic evaluation showed multiple vesicular grouped lesions on the left earlobe [Figure:3]. Such lesions are known to occur due to herpes zoster. Except for blood transfusion 12 years earlier, no other source of HIV infection was elicited in this patient.
He was treated with oral acyclovir (800 mg five times daily) and oral prednisolone (40 mg daily) along with topical prednisolone acetate 1% (six times daily) and homatropine 1% (twice daily). In addition, topical timolol maleate 0.5% twice daily, and oral acetazolamide 250 mg three times daily, were given. The patient showed marked improvement as the perichondritis as well as the uveitis started resolving, but he was lost for follow up after one week. Efforts to reach him by mail were unsuccessful.
Haemorrhagic hypopyon, though uncommon, is known to occur in recurrent severe iridocyclitis, sometimes associated with herpes simplex infections, erythema nodosum, gonococcal infections, gout, rheumatoid arthritis and VZV infections. Occasionally hyphaema with pseudohypopyon may resemble this picture, as in cases of leukaemia, iris tumours such as juvenile xanthogranuloma, melanoma and masquerade syndromes. HIV patients with herpes zoster ophthalmicus may have acute anterior uveitis in about 53% of cases. However, a Medline search revealed no reports of haemorrhagic hypopyon in HIV-positive patients.
In the present case, the clinical feature of perichondritis in the left ear along with severe anterior uveitis and blood-tinged hypopyon, was strongly indicative of HZO. The iris atrophic patches seen in this patient are also common in HZO-associated uveitis. These are known to occur as a result of secondary ischaemia due to occlusive vasculitis.
The antigen detection by direct immunofluorescence is the method of choice for laboratory identification of VZV. With VZV infection proven by this technique, HIV infection was strongly suspected and finally confirmed by the ELISA and Western blot test. Clinically, the presence of peripheral retinal vasculitis and sheathing in HZO greatly increases the suspicion of coexisting HIV infection. Though fundus could not be seen in detail due to the media haze in this patient, an area of retinal haemorrhage surrounded by a zone of ischaemia was seen in the posterior pole, which could be due to VZV retinitis.
With the number of HIV-positive patients on the rise, and ocular involvement in a significant number of them, it is very important to keep in mind the various modes of presentation of such cases. This case shows that blood-tinged hypopyon uveitis caused by VZV infection can be the initial ocular manifestation of AIDS.
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