Chronic Unilateral Endophthalmitis in a Returning Traveller
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Purpose
We present the case of a 24-year-old woman incorrectly diagnosed as having a unilateral non-infectious uveitis following a trip to South America.
Methods
The patient presented with pain, redness, blurred vision and photophobia in her right eye 2 months after returning from South America, and was diagnosed with unilateral anterior uveitis. This failed to settle on conventional therapy with steroids, and treatment was sequentially augmented to include a variety of secondary non-corticosteroidal immunomodulatory therapeutic agents and steroid implants. Extensive investigations including blood tests, repeat aqueous sampling and PET-CT imaging yielded no definitive cause. Her eye failed to quiesce, and she developed severe anterior segment inflammation with recurrent hypopyon. After 5 years of unsuccessful treatment, metagenomic sequencing of aqueous fluid was carried out. Both DNA and RNA of Leptospira santarosai were detected, indicating transcriptional activity and changing the diagnosis to one of chronic unilateral endophthalmitis.
Results
Following a 3-week course of oral moxifloxacin, the intraocular inflammation at last disappeared, allowing discontinuation of systemic immunosuppression.
Conclusion
This case challenges the widely held view of leptospiral uveitis as a post-infectious immune-mediated condition, and instead highlights its potential to cause chronic endophthalmitis. Clinical worsening of presumed non-infectious uveitis following immunosuppression should elicit suspicion of an infectious aetiology, even several years after travel abroad. Metagenomic testing, though costly and not widely available, proved transformative in diagnosing and managing this challenging case.
Conflict of interest
No
1
Last name
LIM
Initials of first name(s)
CXY
Department
Royal Free London NHS Foundation Trust
City
London
Country
United Kingdom
2
Last name
Ramsewak
Initials of first name(s)
S
Department
Medical Eye Unit, St Thomas' Hospital
City
London
Country
United Kingdom
3
Last name
Chu
Initials of first name(s)
C
Department
Moorfields Eye Hospital
City
London
Country
United Kingdom
4
Last name
Albur
Initials of first name(s)
M
Department
Infectious Diseases and Microbiology, North Bristol NHS Trust
City
Bristol
Country
United Kingdom
5
Last name
Clare
Initials of first name(s)
G
Department
Moorfields Eye Hospital
City
London
Country
United Kingdom
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