Diagnostic dilemma: Unilateral panuveitis mimicking endophthalmitis in very severe HLA B27-associated uveitis

To report a case of a 28-years-old male who presented with a worsening unilateral panuveitis after intensive topical steroid therapy which resulted in a diagnostic and treatment dilemma as to whether the patient should be treated as for infective endophthalmitis despite no immediate known infective risk factors.

A patient presented initially with unilateral non-granulomatous acute anterior uveitis which worsened after being started on intensive steroid therapy, developing fibrinous panuveitis. The rapid worsening of inflammation and vision deterioration despite being on intensive steroid therapy resulted in the patient subsequently being treated as for infective endophthalmitis. Anterior chamber and vitreous tap were done and intravitreal antibiotics were administered, along with topical antibiotics therapy. Vitrectomy was withheld due to the lack of conclusive evidence of infective etiology and risk factors. Full uveitis and infective workup were done. Investigations were largely unremarkable, and fluid and vitreous cultures were negative. HLA B27 was positive. The patient was subsequently started on systemic oral corticosteroids and improved in terms of his visual acuity, signs and symptoms.

HLA B27-associated uveitis can present in a range of clinical spectrum with the extreme being of unusual severity in the form of fibrinous panuveitis that can mimic infective endophthalmitis. This can lead to a dilemma in management and subject patients to unnecessary risks from diagnostic and therapeutic interventions. Patients under this subgroup may require long term systemic immunosuppression therapy for disease remission and will require long term follow up.