Sir,

Patients infected with human immunodeficiency virus (HIV) with coexisting ocular infections develop enhanced intraocular inflammation following antiretroviral therapy. Such reactions are referred as ‘immune recovery uveitis’ (IRU). IRU is reported in HIV patients with concurrent cytomegalovirus (CMV) retinitis, tuberculosis and Varicella zoster ocular infection.1, 2, 3, 4 We describe a case of severe form of IRU resulting in perforation of the globe following highly active antiretroviral therapy (HAART) and antitubercular treatment.

Case report

Forty-year-old male patient presented with defective vision, pain, and redness in his right eye for 15 days. Ocular examination revealed mutton fat keratic precipitates, 3 mm hypopyon and 2+ cells and flare in the anterior chamber, nodules on iris, and posterior synechiae (Figure 1a). Investigations revealed a positive serology for HIV and sputum and anterior chamber fluid positive for acid fast bacilli. Pulmonary infiltrates on chest radiograph was suggestive of tuberculosis. Patient was started on zidovudine 300 mg, lamivudine 150 mg efavirenz 600 mg, rifampin 600 mg, isoniazid 300 mg, pyrazinamide 1200 mg, and Ethambutol 800 mg. Three weeks after initiation of HAART and antitubercular treatment, he developed severe cough, pain, and complete loss of vision in his right eye. Radiological worsening of pulmonary infiltrates was seen. Right eye showed congestion, fibrinous exudates in anterior chamber and an iris prolapse at 6 O' clock limbus (Figure 1b). A diagnosis of immune recovery uveitis resulting in perforation of the globe was made. Oral steroids was added; however, eye became pthisical.

Figure 1
figure 1

(a) Right eye showing granulomatous keratic precipitates, iris granuloma, and hypopyon. (b) Fibrinous exudates in the anterior chamber and iris prolapse through the perforation site at the limbus.

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Comment

Initiation of antiretroviral therapy results in immune reconstitution and enhanced immuno-pathological response against systemic or ocular opportunistic pathogens. Such immune enhancement results in either appearance of new clinical signs or exacerbation of existing manifestations.1, 2, 3, 4 In patients with coexisting HIV and systemic tuberculosis, initiation of concomitant antitubercular and antiretroviral therapy has resulted in paradoxical worsening and clinical deterioration.3, 4, 5, 6 The pathogenesis of paradoxical worsening of tuberculosis is not well understood. Corticosteroids might help in reducing inflammation. Alternatively, delaying the administration of HAART for the first 2 months of antituberculosis treatment is advised in order to increase adherence to both therapies.6 Owing to high prevalence of TB in HIV-infected patients, recognizing the possibility of immune enhancement and paradoxical worsening clinical picture is important for proper management.