Case Presentation 2010 FOIS Meeting - Uveitis · Manisha Mehta, MD Luis Alonso Gonzalez-Gonzalez,...
Transcript of Case Presentation 2010 FOIS Meeting - Uveitis · Manisha Mehta, MD Luis Alonso Gonzalez-Gonzalez,...
![Page 1: Case Presentation 2010 FOIS Meeting - Uveitis · Manisha Mehta, MD Luis Alonso Gonzalez-Gonzalez, MD Thank You. Title: Case Presentation 2010 FOIS Meeting Author: sana Created Date:](https://reader036.fdocuments.us/reader036/viewer/2022081402/5f0b789c7e708231d430ae57/html5/thumbnails/1.jpg)
CASE PRESENTATION
Sana S. Siddique¹´², C. Stephen Foster ¹´²1Massachusetts Eye Research and Surgery Institution (MERSI), Cambridge, MA2 Ocular Immunology and Uveitis Foundation
![Page 2: Case Presentation 2010 FOIS Meeting - Uveitis · Manisha Mehta, MD Luis Alonso Gonzalez-Gonzalez, MD Thank You. Title: Case Presentation 2010 FOIS Meeting Author: sana Created Date:](https://reader036.fdocuments.us/reader036/viewer/2022081402/5f0b789c7e708231d430ae57/html5/thumbnails/2.jpg)
History of Presenting Illness
54 year old Caucasian female with recurrent unilateral redness and irritation OS
4-5 episodes over 4 years treated with Tobradex
No workup, systemic treatment, or IMT specifically for ocular symptoms
1 month of redness and irritation prior to initial presentation at MERSI
![Page 3: Case Presentation 2010 FOIS Meeting - Uveitis · Manisha Mehta, MD Luis Alonso Gonzalez-Gonzalez, MD Thank You. Title: Case Presentation 2010 FOIS Meeting Author: sana Created Date:](https://reader036.fdocuments.us/reader036/viewer/2022081402/5f0b789c7e708231d430ae57/html5/thumbnails/3.jpg)
Past Medical History
Cutaneous pemphigus vulgarisDiagnosed by skin biopsy in 2004Extensive esophageal involvement initiallyNumerous treatments: multiple courses of oral Prednisone CellCept, Rituxan and IV-Ig (since 2005)
Currently in remission on Rituxan and IV-Ig
DepressionParoxetine
Recurrent genital herpesSystemic Acyclovir
![Page 4: Case Presentation 2010 FOIS Meeting - Uveitis · Manisha Mehta, MD Luis Alonso Gonzalez-Gonzalez, MD Thank You. Title: Case Presentation 2010 FOIS Meeting Author: sana Created Date:](https://reader036.fdocuments.us/reader036/viewer/2022081402/5f0b789c7e708231d430ae57/html5/thumbnails/4.jpg)
Initial Examination
VA sc 20/20 OD, 20/25 OS
Pupils 4>2 OU, no RAPD
CVF full OU
EOM full OU
IOP 20mmHg OU
![Page 5: Case Presentation 2010 FOIS Meeting - Uveitis · Manisha Mehta, MD Luis Alonso Gonzalez-Gonzalez, MD Thank You. Title: Case Presentation 2010 FOIS Meeting Author: sana Created Date:](https://reader036.fdocuments.us/reader036/viewer/2022081402/5f0b789c7e708231d430ae57/html5/thumbnails/5.jpg)
![Page 6: Case Presentation 2010 FOIS Meeting - Uveitis · Manisha Mehta, MD Luis Alonso Gonzalez-Gonzalez, MD Thank You. Title: Case Presentation 2010 FOIS Meeting Author: sana Created Date:](https://reader036.fdocuments.us/reader036/viewer/2022081402/5f0b789c7e708231d430ae57/html5/thumbnails/6.jpg)
Exam OD OS
Lids WNL WNL
Conjunctiva/Sclera White & quiet Diffuse 1+ injection with 3+ superficial& deep vessel injection superiorly witha central white opacity
Cornea Clear Clear
Anterior Chamber Deep and quiet Deep and quiet
Iris Round and reactive
Round and reactive
Lens PSC PSC
![Page 7: Case Presentation 2010 FOIS Meeting - Uveitis · Manisha Mehta, MD Luis Alonso Gonzalez-Gonzalez, MD Thank You. Title: Case Presentation 2010 FOIS Meeting Author: sana Created Date:](https://reader036.fdocuments.us/reader036/viewer/2022081402/5f0b789c7e708231d430ae57/html5/thumbnails/7.jpg)
PLAN??Serologies
Conjunctival & Scleral biopsy for Immunohistochemical staining
![Page 8: Case Presentation 2010 FOIS Meeting - Uveitis · Manisha Mehta, MD Luis Alonso Gonzalez-Gonzalez, MD Thank You. Title: Case Presentation 2010 FOIS Meeting Author: sana Created Date:](https://reader036.fdocuments.us/reader036/viewer/2022081402/5f0b789c7e708231d430ae57/html5/thumbnails/8.jpg)
Laboratory Studies
HLA typing
ACE
Lysozyme
ESR, CRP
C3, C4, CH50,
RF
Properdin factor 3
Bartonella henselae & quintana IgG/IgM
Hepatitis B
ANCA
Antibody testing: SSA
SSB
SS-DNA
DS-DNA
Smith
![Page 9: Case Presentation 2010 FOIS Meeting - Uveitis · Manisha Mehta, MD Luis Alonso Gonzalez-Gonzalez, MD Thank You. Title: Case Presentation 2010 FOIS Meeting Author: sana Created Date:](https://reader036.fdocuments.us/reader036/viewer/2022081402/5f0b789c7e708231d430ae57/html5/thumbnails/9.jpg)
Laboratory Studies
IgE : 298 (<114 normal)
ANA : positive Titer 1:160
Pattern homogenous
C1Q complexes: 8.1 (<4.4 normal)
C3D complexes: 18 (<8 normal)
![Page 10: Case Presentation 2010 FOIS Meeting - Uveitis · Manisha Mehta, MD Luis Alonso Gonzalez-Gonzalez, MD Thank You. Title: Case Presentation 2010 FOIS Meeting Author: sana Created Date:](https://reader036.fdocuments.us/reader036/viewer/2022081402/5f0b789c7e708231d430ae57/html5/thumbnails/10.jpg)
Intraoperative Findings
![Page 11: Case Presentation 2010 FOIS Meeting - Uveitis · Manisha Mehta, MD Luis Alonso Gonzalez-Gonzalez, MD Thank You. Title: Case Presentation 2010 FOIS Meeting Author: sana Created Date:](https://reader036.fdocuments.us/reader036/viewer/2022081402/5f0b789c7e708231d430ae57/html5/thumbnails/11.jpg)
Conjunctival Biopsy: H&E
![Page 12: Case Presentation 2010 FOIS Meeting - Uveitis · Manisha Mehta, MD Luis Alonso Gonzalez-Gonzalez, MD Thank You. Title: Case Presentation 2010 FOIS Meeting Author: sana Created Date:](https://reader036.fdocuments.us/reader036/viewer/2022081402/5f0b789c7e708231d430ae57/html5/thumbnails/12.jpg)
Conjunctival Biopsy: PAS
![Page 13: Case Presentation 2010 FOIS Meeting - Uveitis · Manisha Mehta, MD Luis Alonso Gonzalez-Gonzalez, MD Thank You. Title: Case Presentation 2010 FOIS Meeting Author: sana Created Date:](https://reader036.fdocuments.us/reader036/viewer/2022081402/5f0b789c7e708231d430ae57/html5/thumbnails/13.jpg)
Direct IF staining of conjunctival biopsy with IgG
![Page 14: Case Presentation 2010 FOIS Meeting - Uveitis · Manisha Mehta, MD Luis Alonso Gonzalez-Gonzalez, MD Thank You. Title: Case Presentation 2010 FOIS Meeting Author: sana Created Date:](https://reader036.fdocuments.us/reader036/viewer/2022081402/5f0b789c7e708231d430ae57/html5/thumbnails/14.jpg)
Conjunctival Biopsy: Direct IF
![Page 15: Case Presentation 2010 FOIS Meeting - Uveitis · Manisha Mehta, MD Luis Alonso Gonzalez-Gonzalez, MD Thank You. Title: Case Presentation 2010 FOIS Meeting Author: sana Created Date:](https://reader036.fdocuments.us/reader036/viewer/2022081402/5f0b789c7e708231d430ae57/html5/thumbnails/15.jpg)
Direct IF staining of conjunctival biopsy with anti-HSV IgG
![Page 16: Case Presentation 2010 FOIS Meeting - Uveitis · Manisha Mehta, MD Luis Alonso Gonzalez-Gonzalez, MD Thank You. Title: Case Presentation 2010 FOIS Meeting Author: sana Created Date:](https://reader036.fdocuments.us/reader036/viewer/2022081402/5f0b789c7e708231d430ae57/html5/thumbnails/16.jpg)
Conjunctival Biopsy – HSV IgG
![Page 17: Case Presentation 2010 FOIS Meeting - Uveitis · Manisha Mehta, MD Luis Alonso Gonzalez-Gonzalez, MD Thank You. Title: Case Presentation 2010 FOIS Meeting Author: sana Created Date:](https://reader036.fdocuments.us/reader036/viewer/2022081402/5f0b789c7e708231d430ae57/html5/thumbnails/17.jpg)
Direct IF staining of conjunctival biopsy with anti-VZV antibody (negative control)
![Page 18: Case Presentation 2010 FOIS Meeting - Uveitis · Manisha Mehta, MD Luis Alonso Gonzalez-Gonzalez, MD Thank You. Title: Case Presentation 2010 FOIS Meeting Author: sana Created Date:](https://reader036.fdocuments.us/reader036/viewer/2022081402/5f0b789c7e708231d430ae57/html5/thumbnails/18.jpg)
![Page 19: Case Presentation 2010 FOIS Meeting - Uveitis · Manisha Mehta, MD Luis Alonso Gonzalez-Gonzalez, MD Thank You. Title: Case Presentation 2010 FOIS Meeting Author: sana Created Date:](https://reader036.fdocuments.us/reader036/viewer/2022081402/5f0b789c7e708231d430ae57/html5/thumbnails/19.jpg)
Diagnosis??
Ocular Pemphigus Vulgaris complicated by HSV
![Page 20: Case Presentation 2010 FOIS Meeting - Uveitis · Manisha Mehta, MD Luis Alonso Gonzalez-Gonzalez, MD Thank You. Title: Case Presentation 2010 FOIS Meeting Author: sana Created Date:](https://reader036.fdocuments.us/reader036/viewer/2022081402/5f0b789c7e708231d430ae57/html5/thumbnails/20.jpg)
Treatment
Acyclovir was replaced with Valacyclovir
Ocular inflammation has been quiet for the past 10 months while on therapy with IV-Ig infusions and valacyclovir, without topical steroids
![Page 21: Case Presentation 2010 FOIS Meeting - Uveitis · Manisha Mehta, MD Luis Alonso Gonzalez-Gonzalez, MD Thank You. Title: Case Presentation 2010 FOIS Meeting Author: sana Created Date:](https://reader036.fdocuments.us/reader036/viewer/2022081402/5f0b789c7e708231d430ae57/html5/thumbnails/21.jpg)
Acknowledgements
C.Stephen Foster, MD, FACS, FACR
Quan Nguyen, MD
Mark Dacey, MD
Manisha Mehta, MD
Luis Alonso Gonzalez-Gonzalez, MD
Thank You