Recurrent Episcleritis Research Articles

Tuberculosis-related episcleritis: a case report

Introduction : Tuberculosis (TB) is a leading cause of infectious disease in developing and highly endemic countries. Primarily affects the lungs, but also invariably involves ocular tissue. Association of TB and episcleritis is very rarely documented and no such case has been reported in Indonesia.
 Case Illustration : A 39-year-old female presented with unilateral mild pain and redness of right eye two weeks before admission. It was her fourth episode in one year. Previous steroid and non- steroidal anti- inflammatory drug (NSAID) treatment partially ended her symptoms before reappeared. Rheumatoid disease also TB history of her and her family were denied. There was nodular episcleritis in the inferior part of the right eye. Systemic investigation showed leukocyte and erythrocyte sedimentation rate (ESR) elevation, positive Mantoux test, with normal chest radiograph. Later symptoms and lesion resolved after anti tubercular therapy (ATT).
 Discussion : Episcleritis is mostly idiopathic, only one third of cases are found to be related with systemic condition. Association of tuberculosis with episcleritis is very rare, only a few cases have been reported worldwide. We encountered a case of tubercular episcleritis by the history of recurrent episode which not responding with regular medication, positive Mantoux test and Indonesia’s TB endemic status. Additionally, improvement after ATT also confirmed the diagnosis.
 Conclusion : This case suggests that TB can cause episcleritis, especially in TB endemic countries. TB should be considered in facing recurrent episcleritis cases to avoid unnecessary complications.

Эффективность субконъюнктивального введения триамцинолона ацетонида в лечении хронического рецидивирующего эписклерита, не поддающегося стандартной терапии

Aim. To evaluate the safety and efficacy of the treatment of chronic recurrent episcleritis, not amenable to the standard treatment regimen, by subconjunctival injections of triamcinolone acetonide. Material and methods. Three patients with recurrent episcleritis, low efficacy of treatment with local steroid, non-steroidal anti-inflammatory drugs and a disease duration of more than 6 months were under observation. All were injected with a prepared solution of triamcinolone acetonide (diluted 1:1 with physiological solution 0.9%) subconjunctivally, once according to the original method. No other drugs were prescribed. A comprehensive examination and assessment of the functions of the visual analyzer was carried out before and after the administration of the drug on the 3rd, 7th, 21st days, 3, 6 months. Results. All patients achieved a pronounced clinical effect and there were no relapses throughout the entire observation period. Conclusion. Subconjunctival injections of triamcinolone acetonide proved to be effective and safe in the treatment of episcleritis resistant to the standard treatment regimen. Side effects of the drug (complicated posterior subcapsular cataract, persistent ophthalmohypertension, etc.) were not detected with this method of treatment. Keywords: episcleritis, long-acting glucocorticosteroids, triamcinolone, triamcinolone acetonide, subconjunctival injection

RECURRENT EPISCLERITIS - A RARE PRESENTATION OF MIXED CONNECTIVE TISSUE DISEASE.

Episcleritis refers to inammation of the loose connective tissue between the sclera and the conjunctiva. The majority of episcleritis cases are idiopathic, but 26% to 36% of patients have an associated systemic disorder that is responsible for the pathological process and development of episcleritis. It is also well established that the incidence and prevalence of episcleritis are higher in populations with systemic collagen-vascular disease and autoimmune diseases. However recurrent episcleritis in Mixed Connective Tissue Disease has not been reported before in literature Here we are reporting a case of recurrent bilateral nodular episcleritis as a rare presentation of MCTD.

Tuberculose ocular num Profissional de Saúde

ABSTRACT Introduction Tuberculosis is considered an Occupational Disease in Health Care Professionals and can have pulmonary manifestations or, more rarely, extrapulmonary manifestations, such as Ocular Tuberculosis, which can manifest in different ways. According to the Direção Geral de Saúde, Health Institutions should adopt early detection measures and considers that cases of active Tuberculosis in Health Care Professionals should be considered as an Occupational Disease. Case Report Technical Assistant, 57 years old, in the Physical Medicine and Hospital Rehabilitation service, with a history of recurrent episcleritis in the left eye for one year. She is observed by Ophthalmology and Internal Medicine. No other major complaints or background. She had a positive Mantoux test and a positive Interferon Gamma Release Assay test in a patient already medicated with oral and local corticosteroids, without improvement. It was assumed that it would be Ocular Tuberculosis, despite not being a typical presentation of the disease, but given the recurrence and treatment failure, it was decided to start treatment for Tuberculosis as active disease, with total remission of complaints. Given the occupational exposure, this case was reported as a suspicion of Occupational Illness and she was removed from her workplace until treatment was completed. Discussion Tuberculosis is one of the most important Occupational Diseases in Health Professionals. As an extrapulmonary manifestation, ocular tuberculosis is rare, but it can have strong implications for the patient’s health. Contrary to what has been observed with other occupational infectious diseases, the incidence of Tuberculosis has been increasing, so it is recommended to screen the risk groups. If there is suspicion, the Occupational Physician must remove the worker from the workplace, notify and report the suspicion of occupational disease. Early diagnosis can be difficult, due to the diversity of presentation, and constitutes a considerable clinical challenge, being often a presumptive diagnosis and the basic principles of treatment for extrapulmonary tuberculosis are common to pulmonary tuberculosis. Conclusion Ocular Tuberculosis as a disease presentation is rare and in Health Care Professionals it is an Occupational Disease given the risk of exposure. Occupational Disease participation by Occupational Medicine took into account the workplace and the risks, showing us the importance of correctly analyzing the place and working conditions, as well as the screening, prevention and infection control measures. Keywords: Ocular Tuberculosis; Occupational disease; Biological risk; Healthcare professional, Occupacional Health, Occupational Medicine.

EP12 Chikungunga arthritis mimicking acute seronegative spondyloarthritis

Case report - IntroductionChikungunya is a tropical arbovirus transmitted by female Aedes Aegypti or Aedes Abopitus mosquitos. It is not indigenous to UK but occurs in epidemics in Africa and Asia. It often presents with pyrexia, arthralgia or arthritis, myalgia and a maculopapular rash and can mimic both peripheral and axial inflammatory arthritis as well as more common forms of viral arthritis. It can also become chronic leading to disabling symptoms. The diagnosis should be considered in all patients presenting with early inflammatory arthritis who have travelled to affected areas. Case report - Case descriptionA 57-year-old female developed sudden onset fever along with a macular rash whilst visiting South East Asia. She then developed widespread joint pains and severe inactivity stiffness, particularly affecting her ankles. The rash and fever settled after a few days, but her arthralgia persisted in her cervical spine and both small and large joints. She had a history of recurrent episcleritis and had been investigated for axial spondyloarthropathy two years previously, but MRI imaging of the spine and sacroiliac joints did not show any inflammatory changes.Examination in the rheumatology clinic confirmed right medial epicondylitis, bilateral shoulder tenderness, tenderness over the extensor tendons of the feet and painful cervical spine movement.Investigations revealed high inflammatory markers; CRP 29 (0-10 mg/L) and ESR 48 (0-15 mm/hr), a positive rheumatoid factor but negative anti CCP antibodies and a normal white cell count.Acute seronegative spondyloarthropathy was suspected but Chikungunya serology was requested at the suggestion of the patient, because of the history of a mosquito bite. IgM and IgG antibodies were positive on immunofluorescence, confirming recent infection.She was initially given intramuscular depomedrone and non-steroidal anti-inflammatory drugs (NSAIDs) with a short response but required oral prednisolone 20mg daily to suppress the inflammation in her feet. An MRI confirmed an ankle effusion and peroneal tenosynovitis. After 6 months her symptoms improved, and she was able to stop prednisolone completely and she remains well 9 months after the initial infection.Case report - DiscussionChikungunya infection causes musculoskeletal symptoms in all affected patients, but the clinical presentation can highly variable, from mild joint pain to erosive arthritis. It can be divided into three phases: incubation phase, acute phase, and chronic phase. The incubation phase varies between one to twelve days after the mosquito bite. The acute phase begins with high fever, headache, polyarthralgia/arthritis, lymphadenopathy, and anorexia. Joint involvement is often distal and symmetrical affecting the hands, wrists, shoulders, knees, ankles, and feet. A maculopapular rash is common. Dengue virus and Zika virus infection can present similarly. Treatment for acute Chikungunya fever is supportive. Analgesic, anti-pyretic and NSAIDs are used for symptom relief. During the chronic phase, infected people develop symmetrical, migratory, oligoarticular or polyarticular arthritis with morning stiffness and joint oedema, which can last from months to years.Our patient had a previous history which was consistent with seronegative spondyloarthropathy, an acute presentation of inflammatory arthritis and results and imaging which supported this diagnosis. The correct diagnosis could easily have been missed if a travel history had not been taken and the patient’s suspicions ignored.The best treatment for chronic Chikungunya arthritis is unclear. NSAIDs are often the first treatment but, as in this case systemic steroids are often necessary. Conventional synthetic DMARDs have also been reported efficacious. Biologic DMARDS have been used in resistant cases.Case report - Key learning pointsChikungunya has emerged as a global disease affecting millions of people with significant musculoskeletal morbidity. Any patient has travelled to endemic areas including Africa and Asia, with fever and joint pain should be screened for Chikungunya virus as well as Dengue virus, and Zika virus.Diagnosis is either by RT PCR (positive 0-7 days of infection or Immunoglobulin M (detectable after 5 – 10 day of infection and persists for few months).Treatment is supportive in acute phase, may require low doses of steroids to aid resolution of symptoms. Conventional DMARDS have shown benefit in chronic phase with ongoing synovitis/tenosynovitis. Patients may know more about rare, endemic diseases than their European doctors and their suspicions about potential diagnoses should always be considered.

Chronic large nasal bloody crusting and recurrent episcleritis: Limited granulomatosis with polyangiitis

Chronic large nasal bloody crusting and recurrent episcleritis: Limited granulomatosis with polyangiitis

Congenital Atrichia with Recurrent Episcleritis-A Rare Case Report

Congenital atrichia is a rare disorder and is often associated with various systemic diseases. Ocular involvement has also been reported. We report a rare case of congenital atrichia with recurrent episcleritis. To the best of our knowledge and after an extensive internet search, this is probably the first reported case of congenital atrichia with episcleritis. The association may be a co-incidental finding or may have a broader perspective. Hence, further studies are warranted.

Is Episcleritis Associated to Glaucoma?

The aim of this study was to show possible connection between episcleritis and open-angle glaucoma. This was a retrospective study. Data on 21 patients who suffered from episcleritis and had no previous attack of episcleritis or glaucoma were collected for a period of 8 years (from 2004 to 2011). Six of the 21 patients of the study group (28.6%) were diagnosed as suffering from glaucoma. Four patients had a diffuse conjunctival congestion, 1 had sectoral congestion, and for 1 patient there was no record of conjunctival congestion. Two of the 6 patients with episcleritis and glaucoma experienced recurrent episcleritis events during the follow-up period. This study suggests an association between episcleritis and open-angle glaucoma.

Recurrent Episcleritis in Relation to Menstruation: A Case Report

To describe a case of recurrent episcleritis associated with a patient's menstrual cycle. A retrospective case review of a 39-year-old woman who presented with a 12-year history of recurrent episcleritis in relation to her menstruation. She was seen during an acute attack and started on a reducing regime of topical steroids for 5 weeks. She was then advised to use it a week before and after menstruation. Examination and investigations revealed episcleritis with a negative systems review. After starting the treatment, she was symptom free when reviewed at 4, 8, 14, and 33 weeks. Now, the patient uses topical steroids only 1 week before menstruation. Literature review revealed no recent case reports and provided insufficient evidence to understand this relationship. We recommend increased awareness and reporting because there is a need for more studies to understand this relationship and to provide evidence for management.

Reactivated Varicella Zoster Virus May Cause Peripheral Arterial Thrombosis

To the Editor: The varicella zoster virus (VZV) is a double-stranded DNA virus of the Herpesviridae family. The virus, which causes chicken pox, primarily infects children. Generally, after the infection, the virus becomes latent in ganglionic neurons along the entire neuroaxis. In particular cases, years after the infection, the reactivation of the VZV can cause zoster (shingles). A 71-year-old man had arterial thrombosis after a herpes zoster infection. For 5 years prior to hospital admission, he had been receiving treatment for recurrent episcleritis and temporal arteritis. His first admission was because of numbness in his left hand. Two weeks before admission, he had been diagnosed with a herpes zoster eruption in his left upper extremity matching with the C6 dermatome. When his symptoms began, he was taking 20 mg/day leflunomide and 7.5 mg/day prednisolone. At his first examination, he had no pulse in his left radial artery. Double subtraction angiography of the left upper extremity showed the proximal left radial artery was thin-caliber and occluded (Figure 1). His left hand was supplied from the palmar arch, which included the ulnar artery (Figure 2 … Address correspondence to Dr. M.E. Tezcan; E-mail: engintez{at}yahoo.com

Episcleritis: An association with IgA nephropathy

To report an unusual case of recurrent episcleritis secondary to IgA nephropathy. Observational case report. A 39-year-old man was seen with recurrent episodes of red and painful left eye suggestive of episcleritis. On routine investigations the patient was found to have haematuria and proteinuria. Further investigations led to the diagnosis of IgA nephropathy on kidney biopsy. IgA nephropathy may present with various eye signs without any other systemic clues. This case highlights the importance of some of the basic tests in clinical practice such as urine examination. This can be conveniently done with testing strip and should be considered in the routine investigation of patients with inflammatory eye diseases.

Recurrent episcleritis associated with brucellosis.

To document the clinical course and the treatment of episcleritis associated with brucellosis. Three consecutive cases of patients with recurrent episcleritis associated with brucellosis were evaluated through clinical and laboratory data including serology (tube agglutination), blood culture, and synovial fluid culture. All the patients had ingested contaminated milk and/or fresh cheese. The diagnosis of brucellosis was confirmed by high antibody titer, positive blood culture, negative synovial fluid culture and unresponsive condition to the previous nonspecific therapy for episcleritis and reactive arthritis. The patients responded well to the therapy with doxycycline and rifampicin. We proposed that recurrent episcleritis had a co-occurence with reactive arthritis in the course of the brucellosis, and that it responded well to the antibrucellar antibiotics rather than to steroids. This also implies that brucellosis as a rule is an underlying triggering infection associated with reactive arthritis.

Recurrent episcleritis associated with adult T cell leukaemia.

Recurrent episcleritis associated with adult T cell leukaemia.

Nodules, eosinophilia, rheumatism, dermatitis and swelling (NERDS): a novel eosinophilic disorder

This study presents the clinical and laboratory findings of a novel syndrome associated with eosinophilia. Two young women presented with marked eosinophilia, and large, non-tender compressible articular nodules arising from the tenosynovium of extensor tendons, dermatitis, episodic swelling of the hands and/or feet and pain in adjacent muscles and joints. Tissue specimens were examined by routine haematoxylin and eosin staining, immunofluorescent staining for eosinophil granule major basic protein (MBP) and rhodamine-avidin or tryptase staining for mast cells. Plasma levels of MBP and eosinophil-derived neurotoxin (EDN) were quantitated by immunoassay. The first patient presented in 1967 at the age of 20 and had, in addition to nodules and eosinophilia, dermographism, recurrent episcleritis and axillary urticaria. Biopsy of a nodule showed tenosynovitis with necrotizing granulomas, non-specific vasculitis, eosinophils and eosinophil degranulation as shown by extracellular deposition of eosinophil granule MBP. Her symptoms responded to low-dose, alternate-day prednisone and have remained quiescent over the past 15 yr. The second patient presented in 1990 at the age of 28 with generalized pruritic dermatitis for 15 yr, eosinophilia for 2 yr, subcutaneous nodules and non-limiting pain in several joints. Biopsy of a nodule showed chronic mild tenosynovitis, numerous eosinophils and extracellular deposition of MBP. She remains untreated. Serum IgE values and plasma levels of MBP and EDN were elevated in both patients; mast cells were numerous in their synovial tissue. Based on their clinical courses, these patients reveal the existence of a distinctive, relatively benign eosinophilic disorder with good long-term prognosis.

External ocular findings in lupus erythematosus: a clinical and immunopathological study.

A selected group of 18 patients with systemic lupus erythematosus (SLE) and 30 patients with chronic cutaneous lupus erythematosus (CCLE) showed an unexpectedly high incidence of problems involving the globe or eyelids. Five SLE patients had recurrent episcleritis, two CCLE patients had lower tarsal plaques, and two further CCLE patients had erosion of the lower lid margins associated with conjunctival scarring and symblepharon. This association has not previously been reported. There was an unexpectedly high incidence of deposition of immunoreactants in a linear pattern at the basement membrane zone in normal bulbar conjunctiva, which occurred in both SLE (42%) and CCLE (50%). The significance of these findings is discussed. We believe surface ocular problems in lupus erythematosus to be under-reported and that direct immunofluorescence of bulbar conjunctival biopsy might be helpful in diagnosis.