Cases reported • Arthritis, Rheumatoid; Rheumatoid Arthritis

11/51. Confocal microscopy in ocular chrysiasis.

PURPOSE: To describe the presence of gold salt deposits in the corneal tissue of a patient treated with gold sodium thiomalate through confocal microscopy and to relate our findings to temporary corneal dynamics. methods: A patient who had been treated with gold sodium thiomalate for 6 years was referred from the rheumatology Unit of our center for an ophthalmologic examination. At the time of examination she had been treatment-free for 9 years. Besides visual acuity, the examination included slit-lamp biomicroscopy, intraocular pressure, and fundoscopy. Confocal microscopy performed using a Confoscan P4 instrument with a 40x lens to obtain 15 images per second on an S-VHS video system (Panasonic) for subsequent analysis. RESULTS: The basic layered structure of the cornea was unaffected, but the presence of highly reflective particles was noted. These particles were interpreted as gold deposits in the corneal stroma, especially in the anterior and middle stroma. CONCLUSION: Confocal microscopy is a useful method of evaluating the deposition of gold salts in tissues, particularly the cornea. Its future use will help gain a deeper understanding of corneal metabolism.

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ranking = 1
keywords = ocular
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12/51. Hemorrhagic cystitis with herpes simplex virus type 2 in the bladder mucosa.

A 67-year-old woman who had underlying rheumatoid arthritis and diabetes mellitus had an 8-year history of recurrent hemorrhagic cystitis. During her most recent episode of cystitis, a specimen of urine yielded herpes simplex virus type 2 in culture. A biopsy of the bladder mucosa revealed intranuclear inclusions in multinucleated and mononuclear giant cells that were positive for herpes simplex virus type 2 by immunoperoxidase staining. She had no evidence of infection with herpes simplex virus outside her bladder.

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ranking = 75.451651910582
keywords = herpes simplex, simplex, herpes
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13/51. Disseminated tuberculosis, pulmonary aspergillosis and cutaneous herpes simplex infection in a patient with infliximab and methotrexate.

CASE PRESENTATION: Despite chemoprophylaxis with isoniazid a 58-year-old Creole patient with mild rheumatoid arthritis developed disseminated tuberculosis, pulmonary aspergillosis and cutaneous herpes simplex infection during treatment with infliximab and methotrexate. TREATMENT: The patient received antituberculous drugs (ethambutol, isoniazid, pyrazinamide, rifampicin), amphotericin b, flucytosine, and valaciclovir, along with prolonged intensive care treatment and mechanical ventilation. CONCLUSIONS: The present case confirms that isoniazid prophylaxis (300 mg once daily, during 6 months) does not protect against the reactivation and dissemination of latent tuberculosis. It also shows that combined treatment with infliximab and methotrexate may induce severe immunosuppression with prolonged leukocytopenia and depressed cellular immunity, leading to multiple opportunistic infections. Extensive diagnostic testing, early start of antimicrobial therapy and enteral immunonutrition, and further infection prevention with selective decontamination of the digestive tract may have been the key to a good clinical outcome.

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ranking = 53.894037078987
keywords = herpes simplex, simplex, herpes
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14/51. Drug-induced bilateral transient myopia with the sulphonamide sulphasalazine.

Whereas there are numerous reported ocular side effects from systemic sulpha medication, most are rare and reversible, with myopia being the most common reaction observed. A case report is presented of sudden bilateral onset of -1.0 DS of myopia (from -3.0 to -4.0 DS) in a young adult female following the addition of a sulphonamide (sulphasalazine) to oral non-steroidal anti-inflammatory treatment (meloxicam) for rheumatoid arthritis. The myopia regressed to -3.50 DS after 2 weeks when all medication was withdrawn and stabilised at this level when subsequent treatment was resumed after 8 weeks with the non-steroidal anti-inflammatory drug celecoxib. The case indicates that account needs to be taken of the possibility that relatively modest myopic shifts encountered in young adult contact lens wearers may be associated with concomitant systemic medication.

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ranking = 0.2
keywords = ocular
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15/51. Peripheral keratitis following laser in situ keratomileusis.

PURPOSE: To report two different cases of sterile, peripheral keratitis following laser in situ keratomileusis (LASIK). methods: A report of two cases (two eyes of two patients). RESULTS: In two patients, peripheral infiltrates appeared 1 day after LASIK. One patient had a history of rheumatoid arthritis and both had peripheral corneal changes that may have represented prior inflammatory events. The presentations were quite different, with one occurring in association with an epithelial defect at the edge of the flap and the other occurring without an epithelial defect peripheral to the microkeratome cut. In the second case a similar infiltrate showed up in the unoperated fellow eye. Both patients were treated with aggressive antibiotic and corticosteroid therapy. Both patients recovered well with no loss of best spectacle-corrected visual acuity. CONCLUSION: Peripheral keratitis can occur in patients following LASIK; preoperative evidence of previous inflammation may be a marker for patients at higher risk. Rheumatoid arthritis patients may be at increased risk for this complication. With careful and aggressive management excellent visual outcomes are still possible.

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ranking = 116.18350911952
keywords = keratitis
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16/51. Anterior scleritis: three case reports and a review of the literature.

BACKGROUND: scleritis is a rare ocular condition involving vasculitis. It can result in severe ocular morbidity and has a high association with underlying systemic disease and mortality. Management can be challenging and under-diagnosis is a concern. Treatment usually requires systemic medications and co-management with a medical specialist in the appropriate field to manage any underlying systemic etiology. methods: Three cases are presented: idiopathic nodular scleritis with complete recovery; bilateral, diffuse anterior scleritis with rheumatoid arthritis; and scleromalacia perforans treated with chemotherapeutic agents and co-managed with a rheumatologist. A search of the English language literature is reported, also. RESULTS: The reported cases exemplify much of our knowledge regarding scleritis. The literature review focuses on the challenges of an accurate diagnosis and management. Management is challenging and, although standards exist, controversy remains. The literature discusses the relationship of scleritis to underlying systemic disease and the significant implication of this association. CONCLUSION: knowledge of scleritis may aid in determining a timely and accurate diagnosis and treatment of both the ocular and any underlying systemic conditions, thus decreasing morbidity and mortality.

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ranking = 0.6
keywords = ocular
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17/51. DRESS syndrome in a patient on sulfasalazine for rheumatoid arthritis.

DRESS (Drug Rash with eosinophilia and Systemic Symptoms) is a drug-induced hypersensitivity syndrome that can mimic malignant lymphoma. We report a case in a 63-year-old woman who had been on sulfasalazine for 2 months to treat rheumatoid arthritis. She was admitted a few days after onset of a flu-like syndrome with a pruriginous maculopapular erythema initially involving the face, trunk, and proximal limbs; a fever of 41 degrees C; and enlargement of the liver, spleen, and several peripheral lymph nodes. blood tests showed marked eosinophilia (9300/mm3), lymphocytosis, hyperbasophilic cells, and severe inflammation. DRESS syndrome was diagnosed. An indirect immunofluorescence assay for human herpesvirus 6 (HHV6) was positive, supporting recent HHV6 infection. Primary HHV6 infection and HHV6 reactivation have been incriminated in the genesis of DRESS syndrome. DRESS syndrome continues to carry a high mortality rate of about 10%. Drugs previously reported to cause DRESS syndrome include sulfasalazine, hydantoin, d-penicillamine, allopurinol, hydrochlorothiazide, and cyclosporine. A high index of suspicion for DRESS syndrome should be maintained in patients receiving these drugs. Serological tests for HHV6 should be performed routinely in patients with suspected DRESS syndrome, although uncertainty persists about the link between HHV6 infection and DRESS syndrome.

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ranking = 0.96497945923897
keywords = herpes
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18/51. Necrotizing scleritis of scleral flaps after transscleral suture fixation of an intraocular lens.

A 56-year-old woman with rheumatoid arthritis underwent intracapsular cataract extraction and sulcus fixation of an intraocular lens using transscleral fixation sutures buried under partial-thickness scleral flaps. Necrotizing scleritis confined to the area of the scleral flaps developed one month postoperatively, resulting in exposure and loosening of one fixation suture and lens implant decentration. The scleritis responded to systemic prednisone and cyclophosphamide treatment, with healing in two weeks. The final visual acuity was 20/30. Surgical trauma may stimulate local intravascular immune complex deposition and initiate the inflammatory process, thereby leading to necrotizing scleritis. This process should be considered when contemplating the use of scleral flaps in patients with collagen vascular disease and systemic vasculitis.

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ranking = 1
keywords = ocular
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19/51. Amniotic membrane transplantation and fibrin glue in the management of corneal ulcers and perforations: a review of 33 cases.

PURPOSE: To evaluate the efficacy of amniotic membrane in corneal ulcers refractive to conventional treatment and amniotic membrane with fibrin glue in corneal perforations. methods: Amniotic membrane transplantation (AMT) was performed in 33 eyes from 32 patients for corneal ulcers refractive to conventional treatment. Fourteen ulcers were perforated and received fibrin glue and amniotic membrane. Ulcers were divided into 3 groups: neurotrophic or exposure, autoimmune, and other etiology. RESULTS: Overall success was observed in 80% (27/33 eyes) of the cases, with success rates of 87.5% (14/16 eyes), 70% (7/10 eyes), 85.7% (6/7 eyes) in groups 1, 2, and 3, respectively. The ulcers healed in a mean time of 3.6 +/- 1.6 weeks and the follow-up was 14.8 +/- 9.9 months. Failure was noted in 6 eyes with severe neurotrophic keratitis, stevens-johnson syndrome, ocular cicatricial pemphigoid, and acanthamoeba keratitis. Grafts with fibrin sealant showed a success rate of 92.9 % (13/14 eyes) compared to 73.7% (14/19 eyes) for amniotic grafts alone. In patients with severe limbal damage, a success rate of only 20% (1/5) was observed. CONCLUSIONS: AMT is a viable option in the treatment of nonhealing corneal ulcers of various depth and etiologies. Perforations up to 3 mm can be safely managed by fibrin glue and AMT. These techniques lead to rapid reconstruction of the corneal surface and can give a good final functional result or allow keratoplasty to be done in more favorable conditions.

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ranking = 38.927836373172
keywords = keratitis, ocular
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20/51. Therapy of progressive rheumatoid arthritis-associated corneal ulceration with infliximab.

PURPOSE: To review the relative efficacy of the TNFalpha antagonist infliximab in treating 3 patients with rheumatoid arthritis-associated peripheral ulcerative keratitis. methods: Review of the clinical course of 3 nonconsecutive patients with progressive rheumatoid arthritis-associated peripheral ulcerative keratitis who were initially treated with conventional immunosuppressant therapy and subsequently treated with infliximab. RESULTS: All 3 patients experienced progressive corneal ulceration on oral prednisone and weekly oral or intramuscular methotrexate. They all demonstrated a marked reduction in conjunctival injection, closure of their corneal epithelial defects, and arrest of corneal thinning after receiving infliximab. Two out of 3 patients required patch grafts for treatment of corneal perforations before starting infliximab, and they had no further keratolysis after receiving this agent. CONCLUSIONS: Infliximab was effective in arresting progressive rheumatoid arthritis-associated peripheral ulcerative keratitis that was refractory to conventional immunomodulatory therapy.

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ranking = 58.091754559758
keywords = keratitis
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