A 35-year-old male presented to our center (Khalili Hospital, Shiraz, Iran) with a chief complaint of pain and redness in both eyes 3 days prior to the presentation. The patient’s medical history was unremarkable. He had a history of river water consumption 20 days prior to the presentation. He had no symptoms and signs of fever, diarrhea, jaundice, abdominal pain, morning stiffness, articular pain, and oral aphthous lesions. The ocular pain and redness started suddenly with mild photophobia 3 days before his presentation. The best corrected visual acuity (BCVA) was 20/25 in the right eye and 20/22 in the left eye. Intraocular pressure was 12 and 14 mmHg in the right eye and left eye, respectively. Slit lamp examinations of both eyes revealed conjunctival injection, variable-sized mutton-fat keratic precipitates in the inferior cornea (Figure 1-A,B), and +3 anterior chamber (AC) cells. The iris, lens, and vitreous were normal. No hypopyon, posterior synechiae and iris atrophy were noted. Fundus examinations were unremarkable in both eyes. The macular optical coherence tomography in both eyes was also normal (Figure 2-A,B). Bilateral granulomatous acute AU was diagnosed.
Three days after ocular presentation, the patient developed low-grade fever, non-productive cough, nausea, vomiting, and yellowish sclera. Routine laboratory tests including complete blood count, erythrocyte sedimentation rate, fasting blood sugar, lipid profile, creatinine, thyroid function tests, and calcium and vitamin D levels were all within normal; only the liver function tests revealed increased levels of alanine aminotransferase (ALT) (183U/L), and aspartate aminotransferase (AST) (131U/L). Other investigations showed raised bilirubin (total bilirubin 7.3mg/dl, and direct bilirubin 4.6 mg/dl) and alkaline phosphatase (ALP) (160 U/L) levels. The infectious investigations including Mantoux test, interferon-gamma blood test, human immunodeficiency virus antibody, syphilis serology tests including venereal disease research laboratory and fluorescent treponemal antibody absorption, hepatitis B surface antigen, hepatitis B core antibody, hepatitis C virus (HCV) antibody, anti-leptospira immunoglobulin (Ig) M antibody, serology of Lyme disease, and blood and urine cultures were all unremarkable except for a positive serology of HAV IgM antibody. The rheumatologic tests including anti-nuclear, anti-neutrophil cytoplasmic, anti-mitochondrial, anti-smooth muscle, anti-La and anti-Ro, anti-liver/kidney microsomal type 1, anti-cyclic citrullinated peptide, anti-phospholipid, anti-β2 glycoprotein, anti–thyroid peroxidase, and anti-thyroglobulin antibodies, rheumatoid factor, and serum angiotensin converting enzyme level were unremarkable. The human leukocyte antigen (HLA) B27, and HLA B51 tests were negative. Chest X-ray radiography was normal without hilar lymphadenopathy. The patient was treated with topical corticosteroid eye drop (prednisolone 1%, Sina Daru Co.) six times a day and cycloplegic eye drop (homatropine 2%, Sina Daru Co.) three times a day for two weeks. The HAV infection was managed with supportive care including replacement of fluid. The ocular pain decreased, AC cells disappeared, and the BCVA improved to 20/20. There was no relapse of AU at the one year follow-up. Liver enzymes, and bilirubin returned to the normal levels (ALT:21U/L, AST:16U/L, ALP:112U/L, total bilirubin:0.8mg/dl, and direct bilirubin:0.1mg/dl), and HAV serology test was negative for anti-HAV IgM and positive for anti-HAV IgG within 12 months following the treatment.
Written informed consent was obtained from the patient for publication of this case report and accompanying images.