Uveitis as the only clinical manifestation of poststreptococcal syndrome

Acute Uveitis in a Background of Streptococcal Sepsis: Infective or Inflammatory?

BACKGROUND

The pathophysiology of uveitis in a patient with post-streptococcal syndrome with evidence of bacterial sepsis may be difficult to classify as being infective or an inflammatory etiology.

CASE REPORT

Our patient presented with uveitis with systemic features of reactive arthritis and acute renal failure in a background of sepsis with group A streptococcus. Treatment with topical steroids lead to the resolution of this type of uveitis.

CONCLUSION

It is safe to consider uveitis as being inflammatory rather than infectious and treat appropriately, when evidence suggesting other features of post -streptococcal syndrome are present.

Post-streptococcal uveitis syndrome in a Caucasian population: a case series

BACKGROUND/OBJECTIVES

Uveitis is an uncommon manifestation of post-streptococcal syndrome (PSUS). Despite reports, the condition is often not well recognised. The purpose of this study is to report a case series of children with post-streptococcal uveitis.

SUBJECTS/METHODS

In this retrospective case series, all cases of PSUS were identified from all new paediatric patients diagnosed with uveitis over a 6-year period. Diagnosis of PSUS was based on the following diagnostic criteria: unilateral or bilateral uveitis with positive anti-streptolysin O titres (ASOT) or anti-deoxyribonuclease (anti-DNase) titres, and negative routine investigations for other causes of uveitis.

RESULTS

Eleven Caucasian paediatric patients were diagnosed with PSUS. One had a novel finding of peripheral corneal endotheliopathy, 73% of patients presented in spring or winter months and 88% of eyes had a final VA of better than or equal to 6/12 at a mean follow-up of 22 months. Systemic immunosuppressant treatment was used in 36% of patients. Adalimumab was used in 18% of patient's refractory to other treatment.

CONCLUSIONS

We report on the largest consecutive series of Caucasian patients under 16 years of age with PSUS. We have demonstrated a seasonal preponderance with presentation typically in winter or spring. We report a novel finding of corneal endotheliopathy in one of our PSUS patients. We also report on the benefit of adalimumab in the management of severe cases of PSUS; use of biologics in this particular cohort of uveitis patients has not previously been reported. With aggressive treatment our patients achieved good visual outcomes comparable to other published series.

Unilateral granulomatous post-streptococcal uveitis with elevated tension

PURPOSE

We document a presumptive case of unilateral post-streptococcal uveitis. The affected eye manifested a granulomatous anterior uveitis with elevated intra-ocular pressure (IOP) compared with the contra-lateral eye. This presentation was preceded by a recent streptococcal pharyngitis.

CASE REPORT

An asymptomatic, otherwise healthy 13-year-old black female presented with anterior chamber cells, mutton fat resembling keratic precipitates, and elevated IOP in the left eye relative to the right eye. The patient had been diagnosed with streptococcal pharyngitis approximately 1 week before her eye examination. A blood chemistry analysis, rheumatoid profile panel and antistreptolysin antibody titer were requested. The patient was prescribed predinisolone acetate 1% ophthalmic suspension in the left eye.

RESULTS

Anti-streptolysin antibody titers were significantly elevated (291 IU/ml). The patient responded favorably to topical ophthalmic steroid treatment with a reduction of IOP and inflammation.

CONCLUSIONS

Unilateral, granulomatous anterior uveitis may be a variant manifestation of post-streptococcal uveitis. The IOP elevation in these cases may result secondary to concurrent trabeculitis.

Poststreptococcal syndrome uveitis: a descriptive case series and literature review

PURPOSE

To describe the clinical features in a series of patients with poststreptococcal uveitis and to review literature on the pathophysiology and management.

DESIGN

Retrospective and descriptive case series.

PARTICIPANTS

Ten consecutive cases of poststreptococcal syndrome uveitis diagnosed between 1996 and 2003.

METHODS

Review of patient case notes.

MAIN OUTCOME MEASURES

Age, laterality, clinical features, and anti-streptococcal lysin O titers.

RESULTS

Ten consecutive cases of poststreptococcal syndrome uveitis were identified. All our cases had bilateral nongranulomatous inflammation and raised anti-streptococcal lysin O titers. Collating data from previous reports and this series showed that 96% of the patients were below 40 years of age, and 87.5% had evidence of previous streptococcal infection. One third of the patients had posterior segment involvement. In our patients, this was in the form of vitritis, focal retinitis, optic disc swelling, and multifocal choroiditis.

CONCLUSIONS

Poststreptococcal syndrome uveitis should be considered in the etiology of acute bilateral nongranulomatous uveitis in children and young patients.

Post-streptococcal uveitis

PURPOSE

To describe the clinical features of post-streptococcal uveitis (PSU) and examine management strategies in the treatment of this under-recognized condition.

METHODS

Patients were identified from the world literature using the Pubmed search engine. We examined two new cases of post-streptococcal intermediate uveitis. The epidemiology, immune mechanisms, clinical features, investigations, treatments and visual outcomes were examined and recorded.

RESULTS

We reviewed 11 patients including our own two cases. There was a statistically significant seasonal difference in antistreptolysin-O titres (ASOT), and age-related ASOT was identified. Of the 11 patients, eight (72.7%) had anterior uveitis, two (18.2%) had intermediate uveitis and one (9.1%) had panuveitis. Their ages ranged from 5 to 56 years (mean 17 years). The majority of cases had significantly elevated ASOT; most patients were treated with topical steroids and oral antibiotics and four cases underwent adenotonsillectomy. The visual prognosis was good in most cases.

CONCLUSIONS

Uveitis may be the sole presenting clinical feature, or it may occur in combination with other features of post-streptococcal infection. Ophthalmologists should be aware of the clinical features of PSU and maintain a high level of suspicion, particularly in childhood uveitis.

Choroiditis, Pigment Epithelial Detachment, and Cystoid Macular Edema as Complications of Poststreptococcal Syndrome

PURPOSE

Two cases of poststreptococcal uveitis are presented. One patient developed nongranulomatous anterior uveitis (case 1). A second patient developed nongranulomatous anterior uveitis followed by granulomatous uveitis with concurrent choroiditis, retinal pigment epithelial detachment, and cystoid macular edema (case 2). Current concepts regarding the pathogenesis of poststreptococcal syndrome and its ocular sequelae are also discussed.

CASE REPORTS

Case 1: A 31-year-old female patient presented with bilateral nongranulomatous uveitis after a recent onset of sore throat. A past diagnosis of rheumatic fever was revealed during acquisition of the patient's history. Blood chemistry analysis indicated elevated anti-streptolysin O antibody titers as the only significant elevated result. Case 2: A 33-year-old female presented initially with bilateral nongranulomatous uveitis. A history of recurrent sore throat was reported. Blood chemistry analysis revealed elevated anti-streptolysin O antibody titers only. "Mutton fat" keratic precipitates eventually developed; however, the bilateral uveitis resolved after topical cycloplegic and corticosteroid treatment. An anterior granulomatous uveitis with concurrent choroiditis, retinal pigment epithelial detachment, and cystoid macular edema ensued during a recurrent episode. Blood chemistry analysis was unremarkable at that time.

CONCLUSIONS

: Anterior nongranulomatous/granulomatous and posterior uveitis should be considered clinical manifestations of poststreptococcal syndrome in patients with a clinical history and/or serological evidence indicating possible past streptococcal infection. A variation of host-genetic-predisposed immune response, the patient's human leukocyte antigen haplotype, pathogen virulence, and/or deposition location of immune circulating complexes may give rise to the diverse spectrum of clinical ocular sequelae in poststreptococcal syndrome. Poststreptococcal uveitis may comprise a similar immunologic pathogenesis to that of acute rheumatic fever, acute glomerulonephritis, and other autoimmune diseases.

Special considerations in the evaluation and management of uveitis in children

PURPOSE

To review issues related to the diagnosis, examination, and treatment of children with uveitis that are important for ophthalmologists.

DESIGN

Literature review.

METHOD

A review was made of pertinent reports from the medical literature, with commentary based on the authors' experiences and on discussions at an international workshop.

RESULTS

There are differences between children and adults in the differential diagnosis and manifestations of uveitis that should be considered during evaluation. There may be a higher risk of some ocular complications such as uveitic glaucoma, and the presence of other unique complications, such as amblyopia, in young patients during follow-up. With regard to treatment, children with uveitis may have unique dosing requirements and drug-associated risks such as growth retardation with systemic corticosteroids that must be considered. Examination and treatment may also be more difficult with children because of problems with patient cooperation.

CONCLUSIONS

There are unique patient care issues associated with uveitis in children that must be considered by care providers. Attention to these issues will improve the well-being of this patient population.

Adenotonsillectomy as a treatment option for poststreptococcal uveitis

OBJECTIVES

To report recurrent uveitis as a manifestation of poststreptococcal syndrome and discuss a role of adenotonsillectomy as a treatment option.

STUDY DESIGN

Case study.

METHODS

A case report of a 6-year-old, otherwise healthy girl with group A streptococcal uveitis managed successfully with adenotonsillectomy.

RESULTS

In the year after surgery there were only two episodes of uveitis, contrasted with a preoperative 3-year history of 8 to 10 annual episodes despite corticosteroid therapy. Moreover, as a result of the postoperative improvement the child was able to avoid impending methotrexate therapy.

CONCLUSIONS

Although the role of tonsillectomy in managing poststreptococcal uveitis is unknown, our results suggest a positive impact independent of the baseline tonsillitis frequency. Otolaryngologists should be aware of these uncommon sequelae of streptococcal infection and the potential role of tonsillectomy in treatment.

Poststreptococcal uveitis

PURPOSE

To report that uveitis may be a manifestation of poststreptococcal syndrome.

METHODS

Case report. Documented attacks of bilateral uveitis were clearly associated with streptococcal infection.

RESULTS

Group A streptococcal infection was evident in all bilateral uveitis attacks, which were treated with local or systemic corticosteroids and penicillin. The frequency and severity of the attacks were reduced by penicillin prophylaxis and tonsillectomy.

CONCLUSIONS

Uveitis should be included as a possible manifestation of poststreptococcal syndrome. If coexisting streptococcal infection is demonstrated, penicillin prophylaxis should be considered.