Jules Gonin Eye Hospital, University Department of Ophthalmology, Avenue de France 15, 1004 Lausanne, Switzerland
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Abstract |
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Introduction |
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Patient and methods |
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Results |
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Discussion |
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Most authors comment on the increased risk of rifabutin-induced uveitis in cases of concomitant treatment with clarithromycin, which was the case in our patient.1,46,911 Simultaneous fluconazole treatment also increases the risk. This phenomenon can be explained by the elevation of serum levels of rifabutin seen with concomitant treatment with macrolides and/or azole derivatives. Both of these classes of drugs, in particular azole derivatives, could inhibit hepatic metabolism of rifabutin via the P450 cytochrome system.1,6 Shafran et al.5 conducted a prospective randomized study including 119 patients, 50 of whom were on a regimen of rifabutin, clarithromycin and ethambutol; 23 of these 59 patients presented with uveitis, which developed at an average of 65 days after initiation of this treatment.5 Our patient was treated with the same three drugs.
The pathogenetic mechanisms of rifabutin-induced uveitis in MAC-infected patients have not yet been elicited. Jacobs et al.4 concluded from their study that a MAC bacteraemia is unlikely to induce uveitis per se, because MAC uveitis (without rifabutin) is seldom seen, and because an anterior chamber tap failed to show any microorganism on direct microscopic examination or on culture. Some authors think that uveitis could be a result of the formation of anti-rifabutin antibodies or of immunoglobulins directed against a rifabutinprotein complex (serum or tissue protein), similarly to what is already known with rifampicin.12 However, rifabutin in vivo does not alter cellular immunity nor does it decrease the number of circulating CD4 lymphocytes.7 Saran et al.1 deduced from their observations that rifabutin-induced uveitis is probably not T-lymphocyte dependent, since it has been seen in AIDS patients in the vast majority of cases.
The striking feature in our case was the onset of CMO on day 7, the patient being already treated with topical corticosteroids and mydriatics. To our knowledge, no case of CMO has been described previously in association with rifabutin, and our patient did not have any predisposing factor for CMO (diabetes mellitus, antecedents of central retinal vein occlusion, previous ocular surgery, previous uveitis). The clinical outcome was favourable after a single posterior sub-Tenon':s triamcinolone injection of 40 mg, topical diclofenac and oral acetazolamide.
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Notes |
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References |
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2
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Fuller, J. D., Stanfield, L. E. D. & Craven, D. E. (1994). Rifabutin prophylaxis and uveitis. New England Journal of Medicine 330, 13156.
3 . Havlir, D., Torriana, F. & Dube, M. (1994). Uveitis associated with rifabutin prophylaxis. Annals of Internal Medicine 1212, 5102.
4 . Jacobs, D. S., Piliero, P. J., Kuperwaser, M. G., Smith, J. A., Harris, S. D., Flanigan, T. P. et al. (1994). Acute uveitis associated with rifabutin use in patients with human immunodeficiency virus infection. American Journal of Ophthalmology 118, 71622.[ISI][Medline]
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Shafran, S. D., Deschênes, J., Miller, M., Phillips, P. & Toma, E. (1994). Uveitis and pseudojaundice during a regimen of clarithromycin, rifabutin and ethambutol. New England Journal of Medicine 330, 4389.
6 . Tseng, A. L. & Walmsley, S. L. (1995). Rifabutin-associated uveitis. Annals of Pharmacotherapy 29, 114955.[Abstract]
7 . Siegal, F. P., Eilbott, D., Burger, H., Gehan, K., Davidson, B., Kaell, A. T. et al. (1990). Dose-limiting toxicity of rifabutin in AIDS-related complex: syndrome of arthralgia/arthritis. AIDS 4, 43341.[ISI][Medline]
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Frank, M. O., Graham, M. B. & Wispelway, B. (1994). Rifabutin and uveitis. New England Journal of Medicine 330, 868.
9 . Jewelewicz, D. A., Schiff, W. M., Brown, S. & Barile, G. R. (1998). Rifabutin-associated uveitis in an immunosuppressed pediatric patient without acquired immunodeficiency syndrome. American Journal of Ophthalmology 125, 8723.[ISI][Medline]
10 . Bhagat, N., Read, R. W., Rao, N. A., Smith, R. E. & Chong, L. P. (2001). Rifabutin-associated hypopyon uveitis in human immunodeficiency virus-negative immunocompetent individuals. Ophthalmology 201, 7502.
11 . Kelleher, P., Helbert, M., Sweeney, J., Anderson, J., Parkin, J. & Pinching, A. (1996). Uveitis associated with rifabutin and macrolide therapy for Mycobacterium avium intracellulare infection in AIDS patients. Genitourinary Medicine 72, 41921.[ISI][Medline]
12 . Moorthy, R. S., Valluri, S. & Jampol, L. M. (1998). Drug-induced uveitis. Survey of Ophthalmology 42, 55770.[ISI][Medline]
Received 30 April 2001; returned 4 October 2001; revised 2 November 2001; accepted 22 November 2001