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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 3  |  Page : 524-525

Intermediate uveitis: A rare diagnosis of brucellosis in eastern India


Regional Institute of Ophthalmology, Kolkata, West Bengal, India

Date of Submission26-Sep-2020
Date of Acceptance03-Feb-2021
Date of Web Publication02-Jul-2021

Correspondence Address:
Dr. Bratatee Roy
Landmark Apartments, Anil Nagar, Rajgarh Link Road, Guwahati, Assam - 781 007
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_3024_20

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  Abstract 


Brucellosis is endemic to India but remains highly underdiagnosed. We report an unusual case of intermediate uveitis with Brucella etiology (BE). A 45-year old female from eastern India complains of diminution of vision and floaters in both eyes (BE), worsening over the last 6 months. Previously, she received on and off oral steroids for 2 years. Her BCVA in right eye (RE) was 20/160 and left eye (LE) was 20/200. She had old keratic precipitates, posterior subcapsular cataract, and vitritis in BE. On ELISA, she was positive for Brucella IgM antibodies. Subsequently, oral antibiotics improved her vision. Ocular involvement in brucellosis, can cause severe vision-threatening complications. An early diagnosis of brucellosis can thus save sight.

Keywords: Eastern India, intermediate uveitis, ocular brucellosis


How to cite this article:
Baidya K, Roy B, Jain S. Intermediate uveitis: A rare diagnosis of brucellosis in eastern India. Indian J Ophthalmol Case Rep 2021;1:524-5

How to cite this URL:
Baidya K, Roy B, Jain S. Intermediate uveitis: A rare diagnosis of brucellosis in eastern India. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 28];1:524-5. Available from: https://www.ijoreports.in/text.asp?2021/1/3/524/320098



 Brucellosis More Details is a zoonotic infection caused by the organism  Brucella More Details abortus or B. melitensis, a Gram-negative bacteria, first isolated by Sir David Bruce from British soldiers in Malta. Transmission to humans is via contact with contaminated fluid from animals like goats, cows, pigs, sheep or via ingestion of unpasteurized milk products or via aerosol inhalation.[1] This is especially commoner in the rural areas where contact with such animals is higher.

Brucellosis symptoms are mostly flu-like, varying from fever, malaise, loss of appetite, muscle fatigue to weight loss. Serious complications like meningoencephalitis are very rare. Ocular features are an unusual presentation of the systemic disease.[2] Antibiotics effective in an acidic environment (rifampicin, doxycycline) are the mainstay of treatment. We report a case of intermediate uveitis caused by Brucellosis, a very rare and under-recognized cause in India.


  Case Report Top


A 45-year-old woman, an ASHA employee working in the rural areas of eastern India presented with redness, gradual diminution of vision, and floaters in both eyes for the last 2 years. There was a significant past history of intermittent fever and redness in both eyes for which oral and topical steroids were prescribed elsewhere, yielding no permanent relief from her symptoms. However, other symptoms like joint pain or backache were absent with no past history of any surgery or co-morbidities.

On presentation to us, her right eye best-corrected visual acuity (BCVA) was 20/160 and left eye BCVA was 20/200. Slit-lamp examination revealed old keratic precipitates and posterior subcapsular lenticular opacities in both eyes. Fundoscopy with an indirect ophthalmoscope showed a grade 4 vitreous haze in both eyes with barely visible optic discs [Figure 1].
Figure 1: (a) Right eye fundus photo shows dense vitreous haze with just visible optic disc; (b) left eye fundus photo shows dense vitreous haze with just visible optic disc

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Both eyes B-scan USG showed vitreous echoes in the posterior segment with attached retina. A set of routine laboratory investigations (Complete blood picture, blood glucose, C-reactive protein, erythrocyte sedimentation rate, angiotensin-converting enzyme levels, rheumatoid factor) were within normal limits. Serological testing for syphilis, hepatitis, and AIDS and sputum analysis for tuberculosis were negative. A negative RT-PCR report of the aqueous aspirate for MTB confirmed the absence of tuberculosis. Chest X-ray was unremarkable. OCT reading of the macula was not possible due to the media opacities. Blood serology testing was negative for Lyme disease. Lyme disease was considered based on the nature of uveitis (intermediate) and her febrile symptoms. Following this exhaustive search to find out the other possible etiologies of intermediate uveitis and also considering her exposure to livestock, brucellosis was then investigated. Enzyme-linked immunosorbent assay (ELISA) titer of Brucella IgM antibodies was significantly high, that is, 29.37 IU/mL, and it was confirmed by a serum agglutination assay which showed a high positive titer of 1:160. A diagnosis of intermediate uveitis due to brucellosis was made.

She was then immediately started on oral doxycycline (100 mg once a day) and rifampicin (300 mg twice a day) which was continued for 3 months. With time, the vitritis subsided with a clearer view of the posterior fundus with now only the central posterior subcapsular cataract contributing to the poor vision. 6 months later, following both eyes' phacoemulsification, her right eye final BCVA was 20/32 and left eye was 20/20.


  Discussion Top


Green, after evaluating the studies done by 23 authors, reported that the ocular manifestations of brucellosis are mostly identified in the chronic phase of the disease.[3] This could be due to the limited identification of this disease by health care providers and the overall lack of awareness amongst the general population about this zoonotic infection. Rolando et al.[4] conducted a 26- year study in Peru and identified posterior uveitis (35%) and panuveitis (32%) as the commonest ocular manifestations of brucellosis. Others were anterior uveitis, intermediate uveitis, conjunctivitis, keratitis, and neuro-ophthalmological features of papilledema and third nerve palsies. The most common visual complications of brucellosis are cataract, glaucoma, and maculopathies.[5] The highly common idiopathic etiology of intermediate uveitis could probably be the prior reason behind the systemic steroid medication.[6] If the effective symptomatic resolution is achieved, then well and good. However, the side effects of chronic steroid usage have well-known complications.[7]

Initially, she received steroid therapy (topical and oral routes) on multiple occasions for ocular inflammation without proper investigations. On elaborate investigations, after well-known causes of uveitis were ruled out, a high index of suspicion diagnosed brucellosis to be the cause of her chronic ocular inflammation by ELISA IgM antibody detection, and confirmed by a high serum agglutination assay (SAT) titer of ≥1:160.

The studies done on ocular brucellosis manifestations in India are rare and few. Two unusual case reports of ocular features of brucellosis reported in India are pre-macular hemorrhage and serous choroidal detachment.[8],[9] The last known reported 1-year study in eastern India was done in 2016 by Sen et al.[10] which reported four cases of brucellosis with anterior and intermediate uveitis features. This shows how uncommon and under-reported cases of ocular brucellosis are. Treatment of brucellosis has been well established with specific antimicrobial therapy and here also, the patient made a full visual recovery with oral rifampicin and oral doxycycline.


  Conclusion Top


Ocular brucellosis, an easily detected disease, should be included in the workup of intermediate uveitis patients in India after more commoner causes have been excluded.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mantur BG, Amarnath SK, Shinde RS. Review of clinical and laboratory features of human brucellosis. Indian J Med Microbiol 2007;25:188-202.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Ataman Hatipoglu C, Yetkin A, Tuncer Ertem G, Tulek N. Unusual clinical presentations of brucellosis. Scand J Infect Dis 2004;36:695-8.  Back to cited text no. 2
    
3.
Green J. Ocular manifestations in brucellosis (Malta fever; undulant fever). Trans Am Ophthalmol Soc 1938;36:104-26.  Back to cited text no. 3
    
4.
Rolando I, Olarte L, Vilchez G, Lluncor M, Otero L, Paris M, et al. Ocular manifestations associated with brucellosis: A 26-year experience in Peru. Clin Infect Dis 2008;46:1338-45.  Back to cited text no. 4
    
5.
Maini R, O'Sullivan J, Reddy A, Watson S, Edelsten C. The risk of complications of uveitis in a district hospital cohort. Br J Ophthalmol 2004;88:512-7.  Back to cited text no. 5
    
6.
Babu BM, Rathinam SR. Intermediate uveitis. Indian J Ophthalmol 2010;58:21-7.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Babu K, Mahendradas P. Medical management of uveitis–current trends. Indian J Ophthalmol 2013;61:277-83.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Sahin ÁG, Pelit A, Turunc T, Akova YA. Ophthalmoparesis, papillitis and premacular hemorrhage in a case with endocarditis: A rare presentation of brucellosis. Indian J Ophthalmol 2010;58:164-6.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Adusumilli H, Krupa L, Shetty NS, Rao S. Bilateral serous choroidal detachment in brucellosis and its management and outcome: Literature review and case report. Indian J Ophthalmol 2020;68:1204-6.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Sen AN, Banerjee PA, Dutta DE, Pal M, Ray AT, Das SA. Brucellar uveitis in eastern India. Asian J Pharm Clin Res 2016;9:196-200.  Back to cited text no. 10
    


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