A patient with well-controlled HIV on antiretroviral therapy presented to the emergency department with five months of left eye pain, redness, discharge, and blurry vision. Visual acuity in the left eye was found to be 20/60 and slit lamp examination was remarkable for a nasal peripheral crescentic area of corneal ulceration and thinning along the limbus with adjacent conjunctival injection and thickening. Peripheral ulcerative keratitis was diagnosed, and systemic laboratory workup was initiated. Initial treatment consisted of topical steroids and antibiotic drops as well as oral steroid, which led to stabilization of the disease for the first month. The clinical course was thereafter complicated by multiple patient difficulties, including inability to complete the laboratory workup, inability to follow up with a rheumatologist as recommended, and being lost to follow up and running out of medications several times. The disease progressed in both eyes, leading to an eventual perforation in the left eye and necessitating conjunctival recessions and amniotic membrane transplantation in both eyes. The patient was eventually transferred to the hospital for inpatient admission where complete systemic workup was unremarkable, the patient was treated with intravenous steroids, and infectious diseases and rheumatology were consulted and deemed it safe to begin immunomodulatory therapy. The patient was treated with rituximab infusions with stabilization of the disease.
Presentation Date: 02/25/2021
Issue Date: 03/12/2021