Rifabutin-associated anterior uveitis in patients infected with human immunodeficiency virus

Iridocyclitis, arthralgia, and pseudojaundice have been identified as dose-dependent adverse effects in patients with acquired immunodeficiency syndrome (AIDS) who are treated orally with rifabutin for Mycobacterium avium intracellulare complex (MAC) infections. Nine episodes of acute anterior uveitis of varying severity ranging from mild iridocyclitis to anterior uveitis with fibrin or hypopyon, mimicking endogenous metastatic endophthalmitis, occurred in seven patients. At the time of presentation, all seven patients were receiving rifabutin at a dose ranging from 300 to 600 mg daily. Iridocyclitis was bilateral in four of seven patients, in two cases simultaneously and in two cases successively. Inflammation resolved rapidly on treatment with systemic and topical antibiotics, on corticosteroid therapy, and on discontinuation of rifabutin. In two cases of mild iridocyclitis, cessation of rifabutin alone led to resolution of the uveitis. The combination of rifabutin, clarithromycin, and fluconazole may increase the risk for anterior uveitis in patients with AIDS. All of our patients were treated with fluconazole, with clarithromycin, or with a combination of both substances in addition to rifabutin. Identification of rifabutin-induced uveitis is important because hypopyon uveitis in the immunocompromised patient generally evokes intensive and, sometimes, invasive ophthalmic and systemic workup and therapy. We suggest it to be sufficient for resolution of the inflammatory signs to discontinue rifabutin medication.