History of Present Illness
A 28-year-old male presents with gradually worsening vision and floaters in both eyes (OU) for several weeks. There is mild redness, pain, and sensitivity to light. Past medical history is unremarkable except that he recently developed joint and muscle aches after returning from a camping trip in Delaware.
| OD | OS | |
|---|---|---|
| Visual acuity | 20/50 | 20/40 |
| Intraocular pressure (IOP) | 12 | 14 |
| Sclera/conjunctiva | Trace injection | Trace injection |
| Cornea | Clear | Clear |
| Anterior chamber (AC) | Trace cells | Trace cells |
| Iris | Unremarkable | Unremarkable |
| Lens | Clear | Clear |
| Anterior vitreous | 2+ cells, 2+ haze | 2+ cells, 2+ haze |
| Optic nerve | Hyperemic | Hyperemic |
| Macula | Flat | Flat |
| Vessels | Scattered sheathing (Fig. 22A) | Scattered sheathing (Fig. 22B) |
| Periphery | Inferior snowballs ( Fig. 22.1 ) | Inferior snowballs |
Questions to Ask
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Do you recall any tick bite or unusual rash?
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Besides joint and muscle pain, did you have fever, malaise, or fatigue?
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Have you noticed any facial weakness? How about tingling, numbness, or weakness elsewhere in the body?
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Any cough, shortness of breath, or chest pain?
He does not recall a tick bite, but he indeed had mild fever and malaise for a week after his camping trip.
Assessment
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Intermediate uveitis with optic nerve inflammation and retinal vasculitis, OU
Differential Diagnosis
Diseases commonly associated with intermediate uveitis:
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Lyme disease
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Sarcoidosis
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Multiple sclerosis
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Syphilis
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Tuberculosis
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Whipple disease
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Pars planitis (idiopathic)
Working Diagnosis
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Lyme-associated intermediate uveitis, OU
Testing
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Enzyme-linked immunosorbent assay (ELISA) serum Lyme antibody screening, with reflex confirmatory Western blot
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Both may be negative in the initial 2 to 4 weeks after infection, as it takes time for antibodies to develop
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For atypical cases or those that fail to improve with oral or intravenous (IV) antibiotics, consider:
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Fluorescent treponemal antibody absorption (FTA-ABS), rapid plasma reagin (RPR)
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QuantiFERON or purified protein derivative (PPD)
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Angiotensin-converting enzyme (ACE), lysozyme
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Chest x-ray or computed tomography (CT) scan
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Magnetic resonance imaging (MRI) brain
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Management
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Doxycycline 100 mg twice a day (BID) for 10 to 21 days
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Alternatives: amoxicillin 500 mg three times a day (TID) or cefuroxime 500 mg BID for 14 to 21 days
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Neurologic involvement (including ocular disease involving the posterior segment): may need IV therapy; in Europe, oral antibiotics appear to be as effective as IV therapy for meningitis. In the United States, IV therapy is used more commonly. Antibiotic treatment for neurologic involvement is controversial and the type of antibiotic and dosages should be confirmed by a neurologic infectious disease specialist.
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Ceftriaxone 2 g once daily
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Cefotaxime 2 g every 8 hours (q8h)
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Penicillin G 18 to 24 MU/day divided every 4 hours (q4h)
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Topical corticosteroids for nummular keratitis and anterior uveitis, and oral corticosteroids for posterior segment inflammation, once proper antibiotic therapy has been started
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