Prednisolone/sirolimus/triamcinolone

Abstract

Worsening of large B-cell non-Hodgkin’s ocular lymphoma, toxoplasmosis chorioretinitis or syphilis leading to syphilitic retinitis: 3 case reports A case series described two men and one woman, aged 40–60 years, who developed worsening of large B-cell non-Hodgkin’s ocular lymphoma, toxoplasmosis chorioretinitis or syphilis leading to syphilitic retinitis during immunosuppressive treatment with prednisolone, sirolimus or triamcinolone [not all routes and dosages stated; time to reactions onsets not stated]. The 40-year-old woman presented with retinal oedema and intraocular inflammation. She had a history of angiomyolipoma and diabetes mellitus. Four months prior to the presentation, she had undergone dropless cataract surgery for blurred vision in the right and left eyes with unspecified antibiotics and unspecified steroids. After the operation, she experienced increased floaters and blurred vision. Initially, she was diagnosed with retinal oedema and intraocular inflammation. Hence, she received local immunosuppression with prednisolone four times a day for both eyes. However, no effect was observed. She also received immunosuppressive treatment with sirolimus. At presentation, her corrected distance visual acuity (CDVA) was 20/300 in the left eye and 20/30 in the right eye. Her ocular examination was notable for 1+ vitreous cells and 1+ anterior chamber cells. The dilated fundus examination showed a placoid-like lesion in the left eye and areas of retinal vascular sheathing and areas of retinal whitening in the macula. Her laboratory examination for tuberculosis, sarcoidosis, toxoplasmosis and syphilis were negative. The diagnostic pars plana vitrectomy with biopsy of the subretinal lesion on the left eye was done, which confirmed the diagnosis of large B-cell non-Hodgkin’s ocular lymphoma. The lumbar puncture and brain MRI did not show any central nervous system disease. Subsequently, she was treated with methotrexate, which resulted in the resolution of intraocular disease. Eleven months after the initial presentation, her MRI revealed lymphoma activity in the brain. She received unspecified systemic chemotherapy, and at the time of this report writing, she was inactive. It was considered that primary ocular lymphoma occurred after dropless cataract surgery with unspecified steroids, which was worsened following treatment with prednisolone and sirolimus. The 60-year-old man presented with uveitis and decreased vision. He had a history of scar in the right eye for years, and recently, he complained of worsening vision. Hence, a cataract was suspected, and 1 month prior to the presentation, he had undergone uneventful dropless cataract surgery with unspecified antibiotics and steroids in the right eye. After the operation, he developed increased floaters and a worsening in vision. Hence, he received local immunosuppressive therapy with prednisolone every 2h for 1 week, which failed to improve his condition. At the presentation, his corrected distance visual acuity (CDVA) was counting fingers in his right eye. His ocular examination revealed keratic precipitates, and 2+ vitreous cells and 3+ anterior chamber cells. The retinal examination revealed arterial thinning and multifocal outer retinal whitening with a patch of whitening adjacent to a chorioretinal scar. In view of clinical presentation and history of an old scar, a diagnosis of toxoplasmosis chorioretinitis was strongly suspected. Therefore, he received a vitreous tap/inject with foscarnet and clindamycin. His serum and vitreous tested positive for toxoplasmosis PCR. He was prescribed double strength cotrimoxazole [sulfamethoxazole/trimethoprim]. Two weeks later, he received a second injection of clindamycin. Three weeks after the presentation, lesion size improved. Subsequently, he started receiving oral prednisone, along with the third injection of clindamycin. Over the next few months, he had an additional recurrence. Nine months after the presentation, his CDVA was counting fingers, and the lesions became inactive. He was continued to receive maintenance prophylaxis therapy. It was considered that toxoplasmosis chorioretinitis occurred after dropless cataract surgery with unspecified steroids, which was worsened following treatment with prednisolone. The 49-year-old man presented with retinitis, sudden vision loss, photophobia and pain. Twenty years prior to the presentation, he was diagnosed with syphilis. Due to bilateral decreased vision, he had undergone dropless cataract surgery with unspecified antibiotics and intravitreal triamcinolone injection in the right eye (2 months prior to presentation) and the left eye (1 month prior to presentation). Few weeks after the operation, he developed acute vision loss in the right eye. A diagnosis of acute retinal necrosis was suspected. At presentation, his corrected distance visual acuity (CDVA) in the right eye was hand motion and in the left eye was 20/25. His clinical examination revealed 1+ anterior chamber cells and vitritis in the right eye. The anterior chamber of his left eye was quiet. The dilated fundus examination showed diffuse outer retinal whitening in his right eye and patchy whitening in his left eye. The optical coherence tomography of the right eye revealed significant retinal thinning, overall layer disorganisation and ellipsoid zone loss. The fluorescein angiography revealed diffuse atrophy and delayed or no perfusion of nasal and temporal areas. In view of his clinical presentation, a diagnosis of syphilis was highly suspected. He tested positive for syphilis immunoglobulin G, and the rapid plasma reagin titer was 1:32. His HIV testing showed a negative result. Hence, he was admitted for the spinal tap, which was venereal disease research laboratory positive, contained numerous cells and varicella-zoster virus immunoglobulin G negative. Subsequently, he was treated with penicillin for 2 weeks. Four days after the presentation, retinal examination revealed improved retinal whitening. Approximately 3 weeks after the presentation, his CDVA remained hand motion. The repeat optical coherence tomography imaging of his right eye showed outer retinal layer loss. Afterwards, he was lost to further follow-up. It was considered that intravitreal treatment with triamcinolone caused worsening of syphilis in the eye leading to syphilitic retinitis.