Bilateral Hypopyons as a Presenting Symptom

Abstract

A 64-year-old man presented with 3 weeks of bilateral anterior uveitis unresponsive to treatment with topical steroids. He was referred to our clinic for worsening uveitis and ocular hypertension. The patient had no ocular history. His medical history was significant for 8 months of bilateral recurrent gingivitis with persistent reactive lymphadenopathy of the head and neck unresponsive to treatment with systemic antibiotics. He denied any constitutional symptoms. His visual acuity was 20/40 OD and 20/200 OS, and intraocular pressures were 17 and 32 mm Hg, respectively. On slitlamp examination, both eyes were markedly hyperemic with diffuse corneal stromal edema, and his anterior chambers were deep with 3+ OD and 4+ OS cell and mixed hypopyon and hyphema in each eye (Figure , A and B). His dilated fundus examination findings were remarkable only for an area of retinal pigment epithelial stippling inferonasal to the macula in the left eye, without any vitritis in either eye. He did not have any skin or mucocutaneous lesions, but he had extensive bilateral preauricular, submental, posterior occipital, and supraclavicular lymphadenopathy. Gram stain and culture of aqueous and vitreous biopsy sample results were negative for infectious and cytologic studies, as were serum human leukocyte antigen B27, tuberculosis, syphilis, and sarcoidosis test results (Figure , C). Hypopyon A Iris nodules B Biopsy sample C 20 µm Figure. Slitlamp examination findings of the left eye with hypopyon (A) and iris nodules (B). C, Aqueous cytology (Wright stain). Note the scant cytoplasm containing small, irregular nuclei with inconspicuous nucleoli. WHAT WOULD YOU DO NEXT? A. Biopsy of iris nodule B. Lymph node biopsy C. Prescribe intravitreal vancomycin and ceftrazidime D. Obtain bacterial and fungal blood cultures Clinical Review & Education