Massive mycobacterial choroiditis during highly active antiretroviral therapy: another immune-recovery uveitis?
OBJECTIVE
To describe the ocular presentation of disseminated mycobacterial disease occurring during immune-recovery in a patient with acquired immune deficiency syndrome (AIDS).


METHODS
Case report and literature review.


METHODS
A 41-year-old AIDS patient with a prior diagnosis of cytomegalovirus retinitis.


METHODS
The patient developed progressive, bilateral multifocal choroiditis with panuveitis 2 months after beginning and responding to highly active antiretroviral therapy. His left eye became blind and painful and was enucleated. Pathologic examination revealed massive choroiditis with well-formed, discrete granulomas and multiple intracellular and extracellular acid-fast organisms within the choroidal granulomas. Culture and polymerase chain reaction of vitreous specimens revealed Mycobacterium avium complex (MAC).


RESULTS
Empiric, and later sensitivity-guided, local and systemic antibiotic therapy was used to treat the remaining right eye, but it continued to deteriorate. Despite medical therapy, three vitrectomies and repeated intravitreal injections of amikacin, a total retinal detachment ensued. One week after the third vitrectomy, the patient died from mesenteric artery thrombosis in the setting of disseminated mycobacterial disease.


CONCLUSIONS
This is the first report of ocular inflammation as the presenting finding in the recently recognized syndrome of immune-recovery MAC disease. Pathogenesis of this entity is related to an enhanced immune response to a prior, subclinical, disseminated infection. The formation of discrete granulomas, normally absent in MAC infections in AIDS, reflects this mechanism.
Zamir
Ehud
E
Doheny Eye Institute, Keck School of Medicine of the University of Southern California, Los Angeles, California 90033, USA.
Hudson
Henry
H
Ober
Richard R
RR
Kumar
Subramanian Krishna
SK
Wang
Robert C
RC
Read
Russell W
RW
Rao
Narsing A
NA
D017088:AIDS-Related Opportunistic Infections / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology*; D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D002833:Choroiditis / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology*; D017726:Cytomegalovirus Retinitis / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology; D004269:DNA, Bacterial / Q000235:genetics; D015818:Eye Infections, Bacterial / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology*; D017809:Fatal Outcome; D006099:Granuloma / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology; D006801:Humans; D008297:Male; D015269:Mycobacterium avium Complex / Q000235:genetics / Q000302:isolation & purification*; D015270:Mycobacterium avium-intracellulare Infection / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology*; D015864:Panuveitis / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology*; D016133:Polymerase Chain Reaction
D004269:DNA, Bacterial