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Metastatic Anterior Chamber Non-Hodgkin Lymphoma in a Patient With Acquired Immunodeficiency Syndrome
FIGURE 2. (Left) Waters view showing thickening of the mucosa and diffuse uniform clouding of both maxil lary (arrow) and frontal (arrowhead) sinuses, consistent with sinusitis. (Right) After systemic therapy with albendazole, Waters view shows normal mucosal thick ness and clearing of the maxillary (arrow) and frontal (arrowhead) sinuses.
nosed, it is important to examine the patient for other sites of involvement. Nonocular sites of potential infection include the bowel, biliary tract, lower respi ratory tract, nasal and sinus mucosa, kidney, and skeletal muscle.1,2 Topical treatment with fumagillin can control and in rare cases, cure, ocular infections but will not affect the infection elsewhere.1,3 Even systemic treatment has often resulted only in control of microsporidial infections rather than cure.1 Albendazole is a broad-spectrum anthelminthic of the benzimidazole class and is effective against larval and adult stages of cestodes and trematodes.4 It has shown promising treatment results for microsporidiosis.1 Its major side effects include hepatotoxicity, neutropenia, and alopecia.5 These effects are revers ible with cessation of therapy. Patients should be monitored with weekly liver function tests and com plete blood cell count. An increase in transaminase activity is common but generally inconsequential in these patients. An experienced internist may be of assistance in following up these patients. This case demonstrates the importance of a thor ough review of systems to evaluate potential sites of microsporidial infection. This case also establishes the potential utility of systemic therapy with albenda zole in patients with AIDS who are diagnosed with ocular microsporidiosis and who are refractory to topical therapy. REFERENCES 1. Weber R, Bryan RT, Schwartz DA, Owen RL. Human microsporidial infections. Clin Microbiol Rev 1994;7: 426-461. 2. Lacey CJ, Clarke AM, Fraser P, Metcalfe T, Bonsor G, Curry VOL.124, No. 2
A. Chronic microsporidian infection of the nasal mucosae, sinuses, and conjunctivae in HIV disease. Genitourin Med 1992;68:179-181. 3. Diesenhouse MC, Wilson LA, Corrent GF, Visvesvara GS, Grossniklaus HE, Bryan RT. Treatment of microsporidial keratoconjunctivitis with topical fumagillin. Am J Ophthalmol 1993;115:293-298. 4. Edwards G, Breckenridge AM. Clinical pharmacokinetics of anthelminthic drugs. Clin Pharmacokinet 1988;15:67-93. 5. Steiger U, Cotting J, Reichen J. Albendazole treatment of echinococcosis in humans: effects on microsomal metabolism and drug tolerance. Clin Pharmacol Ther 1990;47:347-353.
Metastatic Anterior Chamber Non-Hodgkin Lymphoma in a Patient With Acquired Immunodeficiency Syndrome Enrique Espana-Gregori, MD, Mercedes Hernandez, MD, J. L. Menezo-Rozalen, MD, and Manuel Diaz-Llopis, MD PURPOSE: To alert ophthalmologists to the possi bility of metastatic anterior chamber intraocular non-Hodgkin lymphoma in patients with acquired immunodeficiency syndrome (AIDS). METHODS: We examined a 19-year-old man with AIDS who had an anterior uveitis with pseudohypopyon and a history of 2 months of malaise. A specimen of the lesion was obtained with a 25gauge needle for pathologic examination. RESULTS: Systemic exploration showed hepato megaly. Abdominal computed tomography showed multiple lesions in the liver and spleen. Fineneedle aspiration disclosed a high-grade nonHodgkin lymphoma. The result of a fine-needle aspiration obtained from a lesion in the anterior chamber was consistent with the same diagnosis. CONCLUSION: An anterior chamber pseudohypopyon with uveitis can be the manifesting sign of a systemic lymphoma in a patient with AIDS and requires a thorough systemic evaluation. Accepted for publication Jan 2, 1997. Departments of Optics (E.E.-G.) and Ophthalmology (J.L.M.-R.), University of Valencia; Virgen de la Arrixaca Hospital (M.H.); University of the Basque Country (M.D.-L); La Fe Hospital (E.E.-G., J.L.M.-R., M.D.-L.). Supported in part by grant 96/1504 from the Fondo de Investigaciones Sanitarias de la Seguiridad Social, Spain (M.D.-L.). Inquiries to Enrique Espana-Gregori, MD, Plaza Fray Luis Colomer 6-16, Valencia, 46021, Spain.
BRIEF REPORTS
243
H
IGH-GRADE NON-HODGKIN LYMPHOMAS ARE OB-
served in 3% to 10% of patients with acquired immunodeficiency syndrome (AIDS).1,2 The inci dence of such lymphomas has been increasing as the life expectancy of patients with AIDS has increased.3 Intraocular lymphoma usually has been documented in these patients as a part of primary central nervous system disease.4 We present a case of intraocular lymphoma that manifested as a mass in the anterior chamber in combination with anterior uveitis in association with systemic involvement in a patient with AIDS. A 19-year-old man with AIDS and a history of intravenous drug abuse was referred for ophthalmic assessment because of blurred vision in a red and painful right eye. He had a 2-month history of weight loss and a 2-day history of fever and malaise. Visual acuity at initial examination was RE, 20/30 and LE, 20/20. In the right eye, slit-lamp examination showed ciliary congestion, miosis, and an associated intense cellular reaction in the anterior chamber. Ophthalmoscopic examination was normal. Systemic explora tion showed 1 cm of liver enlarged to palpation and laterocervical lymphadenopathies of 0.5 cm. The patient was treated with topical corticosteroids and mydriatics. After 2 days, uveitis had nearly resolved, and his visual acuity was 20/20; however, a white material could be seen emerging from the anterior chamber angle of the right eye (Figure 1). A specimen of the lesion was obtained through a paracentesis with a 25-gauge needle for pathologic examination. Liver ultrasonography showed multiple, well-demar cated, echo-free lesions of 2 to 4 cm in diameter with a posterior shadow. Computed tomography of the abdomen disclosed numerous lesions in hepatic parenchyma and spleen with retroperitoneal lymph adenopathies. Fine-needle aspiration biopsy of intrahepatic lesions was interpreted as a high-grade non-Hodgkin lymphoma. Computed tomography and magnetic resonance of the brain and orbit appeared to be within normal limits. Lumbar puncture was positive for the same malignancy. The result of the fine-needle aspiration biopsy from the lesion in the anterior chamber was consistent with the diagnosis of an intraocular non-Hodgkin lymphoma (Figure 2). The patient was treated with systemic and intrathecal chemotherapy, with a favorable outcome. He died 2
244
FIGURE 1. In the right eye, a mass emerging from the anterior chamber angle was observed after improvement of anterior uveitis (arrow).
FIGURE 2. Fine-needle aspiration biopsy from the material emerging from the chamber angle. Some malig nant cells show immunoreactivity for the common leu kocyte antigen (arrows) (immunoperoxidase with hematoxylin counterstain, X200).
months later because of a respiratory process and meningitis. At least three patterns of intraocular lymphomatous involvement occur.5 In the first, the intraocular findings simulate a diffuse uveitis, usually with a plethora of vitreous cells and often with virtually pathognomonic yellow-white chorioretinal infiltrates. The neoplastic disease is usually limited to the eye and central nervous system. A second, less common form consists of either a similar intraocular manifesta tion or, more commonly, lesions in the choroid with fewer vitreous cells. These patients usually develop systemic, non-central nervous system lymphoma. The third form of involvement can occur as a sequela of systemic lymphoma, often as the first sign of
AMERICAN JOURNAL OF OPHTHALMOLOGY
AUGUST 1997
reactivation after therapy. In this latter group, most frequently, patients develop a malignant hypopyon. The first form of involvement has been described previously in AIDS patients, but this special form of metastatic manifestation as anterior uveitis with pseudohypopyon occurs less frequently, even in patients with other diseases. All patients with intraocular lymphoma require a thorough systemic evaluation including cerebrospinal fluid cytology, brain magnetic resonance imaging, abdominal-chest computed to mography, routine blood studies, and a bone marrow biopsy. An anterior uveitis with pseudohypopyon in a young patient with AIDS can be a sign of metastatic involvement in systemic non-Hodgkin lymphoma. REFERENCES 1. Raphael M, Gentilhomme O, Tulliez M, Byron PA, Diebold J. Histopathologic features of high-grade non-Hodgkin's lymphomas in acquired immunodeficiency syndrome: the French Study Group of Pathology for Human Immunodeficiency Virus-associated Tumors. Arch Pathol Lab Med 1991;115: 15-20. 2. Beral V, Peterman T, Berkelman R, Jaffe H. AIDS associated • non-Hodgkin's lymphoma. Lancet 1991;337:805-809. 3. Matzkin DC, Slamovits TL, Rosenbaum PS. Simultaneous intraocular and orbital non-Hodgkin lymphoma in the ac quired immune deficiency syndrome. Ophthalmology 1994; 101:850-855. 4. Stanton CA, Sloan B, Slusher MM, Greven CM. Acquired immunodeficiency syndrome-related primary intraocular lym phoma. Arch Ophthalmol 1992;110:1614-1617. 5. Dean JM, Novak MA, Chan C, Green WR. Tumor detach ments of the retinal pigment epithelium in ocular/central nervous system lymphoma. Retina 1996;16:47-56.
Damage of Foldable Intraocular Lenses by Incorrect Folder Forceps Lelio Baldeschi, MD, Stanislao Rizzo, MD, and Marco Nardi, MD PURPOSE: To evaluate possible damage of foldable silicone or acrylic intraocular lenses caused by the use of incorrect lens folder forceps. METHODS: Ten silicone and 10 acrylic intraocu lar lenses were divided into two groups, each containing five silicone andfiveacrylic lenses. Two easily mistaken folder forceps, each expressly de signed for either silicone or acrylic lenses only, VOL.124, No. 2
FIGURE 1. (Top) Buratto folder forceps for silicone foldable intraocular lenses, large handle. (Bottom) Bu ratto folder forceps for Acrysof MA60 6.0-mm intraocu lar lenses, great, crossed action.
were properly used to fold the intraocular lenses in group 1 whereas in group 2, the silicone lenses were folded with the forceps designed for the acrylic lenses, and the acrylic lenses were folded with the forceps designed for the silicone lenses. We ob served the lenses by transmission and scanning microscopy after folding. RESULT: The acrylic lenses folded with forceps designed for the silicone lenses (group 2) disclosed considerable damage of the lens optic. CONCLUSION: Incorrect folder forceps may dam age acrylic intraocular lenses.
F
OLDABLE INTRAOCULAR LENSES MUST BE MANIPU-
lated according to the characteristics of the materi al from which they are made. The use of correct folder forceps is therefore important. Such forceps are often similar in appearance and easily mistaken in clinical practice. To evaluate potential damage caused by folding, 10 silicone and 10 acrylic intraocular lenses were examined using transmission and scanning microscopy after folding with two folder forceps designed for either silicone intraocular lenses or acrylic intraocular lenses. Ten silicone (SI30NB AMO silicone intraocular lens, Allergan Medical Optics, Irvine, California) and 10 acrylic (MA60BM Acrysof, Alcon Laborato ries, Fort Worth, Texas) foldable intraocular lenses Accepted for publication April 1, 1997. Section of Ophthalmology, Neurosciences Department, Pisa University. Inquiries to Lelio Baldeschi, MD, Via Putignano 315/C, 56100 Pisa, Italy.
BRIEF REPORTS
245
nosed, it is important to examine the patient for other sites of involvement. Nonocular sites of potential infection include the bowel, biliary tract, lower respi ratory tract, nasal and sinus mucosa, kidney, and skeletal muscle.1,2 Topical treatment with fumagillin can control and in rare cases, cure, ocular infections but will not affect the infection elsewhere.1,3 Even systemic treatment has often resulted only in control of microsporidial infections rather than cure.1 Albendazole is a broad-spectrum anthelminthic of the benzimidazole class and is effective against larval and adult stages of cestodes and trematodes.4 It has shown promising treatment results for microsporidiosis.1 Its major side effects include hepatotoxicity, neutropenia, and alopecia.5 These effects are revers ible with cessation of therapy. Patients should be monitored with weekly liver function tests and com plete blood cell count. An increase in transaminase activity is common but generally inconsequential in these patients. An experienced internist may be of assistance in following up these patients. This case demonstrates the importance of a thor ough review of systems to evaluate potential sites of microsporidial infection. This case also establishes the potential utility of systemic therapy with albenda zole in patients with AIDS who are diagnosed with ocular microsporidiosis and who are refractory to topical therapy. REFERENCES 1. Weber R, Bryan RT, Schwartz DA, Owen RL. Human microsporidial infections. Clin Microbiol Rev 1994;7: 426-461. 2. Lacey CJ, Clarke AM, Fraser P, Metcalfe T, Bonsor G, Curry VOL.124, No. 2
A. Chronic microsporidian infection of the nasal mucosae, sinuses, and conjunctivae in HIV disease. Genitourin Med 1992;68:179-181. 3. Diesenhouse MC, Wilson LA, Corrent GF, Visvesvara GS, Grossniklaus HE, Bryan RT. Treatment of microsporidial keratoconjunctivitis with topical fumagillin. Am J Ophthalmol 1993;115:293-298. 4. Edwards G, Breckenridge AM. Clinical pharmacokinetics of anthelminthic drugs. Clin Pharmacokinet 1988;15:67-93. 5. Steiger U, Cotting J, Reichen J. Albendazole treatment of echinococcosis in humans: effects on microsomal metabolism and drug tolerance. Clin Pharmacol Ther 1990;47:347-353.
Metastatic Anterior Chamber Non-Hodgkin Lymphoma in a Patient With Acquired Immunodeficiency Syndrome Enrique Espana-Gregori, MD, Mercedes Hernandez, MD, J. L. Menezo-Rozalen, MD, and Manuel Diaz-Llopis, MD PURPOSE: To alert ophthalmologists to the possi bility of metastatic anterior chamber intraocular non-Hodgkin lymphoma in patients with acquired immunodeficiency syndrome (AIDS). METHODS: We examined a 19-year-old man with AIDS who had an anterior uveitis with pseudohypopyon and a history of 2 months of malaise. A specimen of the lesion was obtained with a 25gauge needle for pathologic examination. RESULTS: Systemic exploration showed hepato megaly. Abdominal computed tomography showed multiple lesions in the liver and spleen. Fineneedle aspiration disclosed a high-grade nonHodgkin lymphoma. The result of a fine-needle aspiration obtained from a lesion in the anterior chamber was consistent with the same diagnosis. CONCLUSION: An anterior chamber pseudohypopyon with uveitis can be the manifesting sign of a systemic lymphoma in a patient with AIDS and requires a thorough systemic evaluation. Accepted for publication Jan 2, 1997. Departments of Optics (E.E.-G.) and Ophthalmology (J.L.M.-R.), University of Valencia; Virgen de la Arrixaca Hospital (M.H.); University of the Basque Country (M.D.-L); La Fe Hospital (E.E.-G., J.L.M.-R., M.D.-L.). Supported in part by grant 96/1504 from the Fondo de Investigaciones Sanitarias de la Seguiridad Social, Spain (M.D.-L.). Inquiries to Enrique Espana-Gregori, MD, Plaza Fray Luis Colomer 6-16, Valencia, 46021, Spain.
BRIEF REPORTS
243
H
IGH-GRADE NON-HODGKIN LYMPHOMAS ARE OB-
served in 3% to 10% of patients with acquired immunodeficiency syndrome (AIDS).1,2 The inci dence of such lymphomas has been increasing as the life expectancy of patients with AIDS has increased.3 Intraocular lymphoma usually has been documented in these patients as a part of primary central nervous system disease.4 We present a case of intraocular lymphoma that manifested as a mass in the anterior chamber in combination with anterior uveitis in association with systemic involvement in a patient with AIDS. A 19-year-old man with AIDS and a history of intravenous drug abuse was referred for ophthalmic assessment because of blurred vision in a red and painful right eye. He had a 2-month history of weight loss and a 2-day history of fever and malaise. Visual acuity at initial examination was RE, 20/30 and LE, 20/20. In the right eye, slit-lamp examination showed ciliary congestion, miosis, and an associated intense cellular reaction in the anterior chamber. Ophthalmoscopic examination was normal. Systemic explora tion showed 1 cm of liver enlarged to palpation and laterocervical lymphadenopathies of 0.5 cm. The patient was treated with topical corticosteroids and mydriatics. After 2 days, uveitis had nearly resolved, and his visual acuity was 20/20; however, a white material could be seen emerging from the anterior chamber angle of the right eye (Figure 1). A specimen of the lesion was obtained through a paracentesis with a 25-gauge needle for pathologic examination. Liver ultrasonography showed multiple, well-demar cated, echo-free lesions of 2 to 4 cm in diameter with a posterior shadow. Computed tomography of the abdomen disclosed numerous lesions in hepatic parenchyma and spleen with retroperitoneal lymph adenopathies. Fine-needle aspiration biopsy of intrahepatic lesions was interpreted as a high-grade non-Hodgkin lymphoma. Computed tomography and magnetic resonance of the brain and orbit appeared to be within normal limits. Lumbar puncture was positive for the same malignancy. The result of the fine-needle aspiration biopsy from the lesion in the anterior chamber was consistent with the diagnosis of an intraocular non-Hodgkin lymphoma (Figure 2). The patient was treated with systemic and intrathecal chemotherapy, with a favorable outcome. He died 2
244
FIGURE 1. In the right eye, a mass emerging from the anterior chamber angle was observed after improvement of anterior uveitis (arrow).
FIGURE 2. Fine-needle aspiration biopsy from the material emerging from the chamber angle. Some malig nant cells show immunoreactivity for the common leu kocyte antigen (arrows) (immunoperoxidase with hematoxylin counterstain, X200).
months later because of a respiratory process and meningitis. At least three patterns of intraocular lymphomatous involvement occur.5 In the first, the intraocular findings simulate a diffuse uveitis, usually with a plethora of vitreous cells and often with virtually pathognomonic yellow-white chorioretinal infiltrates. The neoplastic disease is usually limited to the eye and central nervous system. A second, less common form consists of either a similar intraocular manifesta tion or, more commonly, lesions in the choroid with fewer vitreous cells. These patients usually develop systemic, non-central nervous system lymphoma. The third form of involvement can occur as a sequela of systemic lymphoma, often as the first sign of
AMERICAN JOURNAL OF OPHTHALMOLOGY
AUGUST 1997
reactivation after therapy. In this latter group, most frequently, patients develop a malignant hypopyon. The first form of involvement has been described previously in AIDS patients, but this special form of metastatic manifestation as anterior uveitis with pseudohypopyon occurs less frequently, even in patients with other diseases. All patients with intraocular lymphoma require a thorough systemic evaluation including cerebrospinal fluid cytology, brain magnetic resonance imaging, abdominal-chest computed to mography, routine blood studies, and a bone marrow biopsy. An anterior uveitis with pseudohypopyon in a young patient with AIDS can be a sign of metastatic involvement in systemic non-Hodgkin lymphoma. REFERENCES 1. Raphael M, Gentilhomme O, Tulliez M, Byron PA, Diebold J. Histopathologic features of high-grade non-Hodgkin's lymphomas in acquired immunodeficiency syndrome: the French Study Group of Pathology for Human Immunodeficiency Virus-associated Tumors. Arch Pathol Lab Med 1991;115: 15-20. 2. Beral V, Peterman T, Berkelman R, Jaffe H. AIDS associated • non-Hodgkin's lymphoma. Lancet 1991;337:805-809. 3. Matzkin DC, Slamovits TL, Rosenbaum PS. Simultaneous intraocular and orbital non-Hodgkin lymphoma in the ac quired immune deficiency syndrome. Ophthalmology 1994; 101:850-855. 4. Stanton CA, Sloan B, Slusher MM, Greven CM. Acquired immunodeficiency syndrome-related primary intraocular lym phoma. Arch Ophthalmol 1992;110:1614-1617. 5. Dean JM, Novak MA, Chan C, Green WR. Tumor detach ments of the retinal pigment epithelium in ocular/central nervous system lymphoma. Retina 1996;16:47-56.
Damage of Foldable Intraocular Lenses by Incorrect Folder Forceps Lelio Baldeschi, MD, Stanislao Rizzo, MD, and Marco Nardi, MD PURPOSE: To evaluate possible damage of foldable silicone or acrylic intraocular lenses caused by the use of incorrect lens folder forceps. METHODS: Ten silicone and 10 acrylic intraocu lar lenses were divided into two groups, each containing five silicone andfiveacrylic lenses. Two easily mistaken folder forceps, each expressly de signed for either silicone or acrylic lenses only, VOL.124, No. 2
FIGURE 1. (Top) Buratto folder forceps for silicone foldable intraocular lenses, large handle. (Bottom) Bu ratto folder forceps for Acrysof MA60 6.0-mm intraocu lar lenses, great, crossed action.
were properly used to fold the intraocular lenses in group 1 whereas in group 2, the silicone lenses were folded with the forceps designed for the acrylic lenses, and the acrylic lenses were folded with the forceps designed for the silicone lenses. We ob served the lenses by transmission and scanning microscopy after folding. RESULT: The acrylic lenses folded with forceps designed for the silicone lenses (group 2) disclosed considerable damage of the lens optic. CONCLUSION: Incorrect folder forceps may dam age acrylic intraocular lenses.
F
OLDABLE INTRAOCULAR LENSES MUST BE MANIPU-
lated according to the characteristics of the materi al from which they are made. The use of correct folder forceps is therefore important. Such forceps are often similar in appearance and easily mistaken in clinical practice. To evaluate potential damage caused by folding, 10 silicone and 10 acrylic intraocular lenses were examined using transmission and scanning microscopy after folding with two folder forceps designed for either silicone intraocular lenses or acrylic intraocular lenses. Ten silicone (SI30NB AMO silicone intraocular lens, Allergan Medical Optics, Irvine, California) and 10 acrylic (MA60BM Acrysof, Alcon Laborato ries, Fort Worth, Texas) foldable intraocular lenses Accepted for publication April 1, 1997. Section of Ophthalmology, Neurosciences Department, Pisa University. Inquiries to Lelio Baldeschi, MD, Via Putignano 315/C, 56100 Pisa, Italy.
BRIEF REPORTS
245