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  • Grand Rounds

    A middle-aged patient presented to the ophthalmology emergency room for bilateral blurry vision for 1 week after recent hospital admission for recurrent pleural effusions. After discharge, he presented to an outside eyecare specialist who referred him to the ophthalmology emergency room. Visual acuity on presentation was 20/200 OD and 20/60 OS and did not improve with pinhole. Intraocular pressure (IOP) was 11 mm Hg OD and 10 mm Hg OS, and pupils were dilated and nonreactive given prior dilation earlier in the day. The anterior segment exam was notable for conjunctival injection, corneal Descemet folds, 1+ cell and flare in the anterior chamber, and granulomatous keratic precipitates OU. Posterior segment exam revealed 2-3+ vitritis OU. No chorioretinal lesions were appreciated on exam. Upon further history, the patient was born in Haiti and moved to the US in 2001, He had been complaining of shortness of breath of exertion and weight loss over the past several months. Upon admission, initial concern was for pneumonia, and specifically tuberculosis when the IFN-γ release assay (IGRA) was positive. However numerous samplings of pleural fluid, pathology staining for acid fast organisms, and induced-sputum acid fast bacteria (AFB) tests were negative. Prominent axillary and mediastinal lymphadenopahy was noted and tissue sampling of these revealed granulomas which tested positive by polymerase chain reaction (PCR) for Tropheryma whipplei. Serum testing also was positive for T. whipplei leading to a diagnosis of Whipple disease. The patient was treated for Whipple disease-associated uveitis, however, given the positive IGRA, and his origin from an endemic location, the infectious disease specialist opted to treat him with four-drug (RIPE) therapy for tuberculosis as well. After treatment initiation he began to improve dramatically and was 20/25 and 20/30 at last follow up with no other ocular sequelae.

    Presentation Date: 12/12/2024
    Issue Date: 02/21/2025