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Discussion

Tuberculosis Uveitis

This is a patient with HIV and an anergic TB skin test one year previous when her CD4 count was low. After starting ART, she was doing well until her granulomatous (mutton fat) uveitis developed. We know this process was long standing because of the central posterior synechiae (pupil being tacked down to the anterior lens capsule by inflammation). We repeated a TB skin test, and it was POSITIVE because now she had a reconstituted immune system to mount a skin response. We also worked her up for syphilis and sarcoid, which were negative. In an HIV patient, the uveitis can be a result of immune reconstitution syndrome (patients are usually much more ill) or from the original HIV infection. The latter is a diagnosis of exclusion.

We referred this patient to internal medicine/infectious disease for treatment. We started her on prednisolone drops (steroid for inflammation) and homatropine or scopolamine (dilation and cycloplegic to prevent further synechial formation and for comfort- it's best to use an intermediate cycloplegic so the pupil can react to prevent peripheral anterior synechiae formation).

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Diagnosis: Granulomatous Uveitis

EPIDEMIOLOGY Variable due to numerous etiologies	SIGNS mutton fat KP anterior segment cell and flare conjunctival/episcleral injection may be associated with an anterior vitritis from spill over synechiae formation Koeppe nodules (cluster of cells on pupil margin) Busacca nodules (cluster of cells on iris)
SYMPTOMS Photophobia Tearing Decreased vision Pain	TREATMENT cycloplegic, scopolamine 0.25% BID prednisolone acetate 1% every 1-4 hours treat secondary glaucoma treat underlying disorder periocular injection of steroids may be needed for severe cases not responding to topical managment.

Differential Diagnoses:

• Sarcoidosis
• Syphilis
• Vogt-Koyanagi-Harada syndrome (associated with posterior retinal findings, poliosis, vitiligo, and sometimes hypopyon)
• Sympathetic ophthalmia
• Multiple sclerosis
• Lyme disease
• Tuberculosis
• Herpes zoster
• Coccidioidomycosis
• Leprosy
• Toxoplasmosis (usually associated with a posterior uveitis)
• Brucellosis
• Idiopathic (includes immune reconstitution syndrome and HIV uveitis)