Sympathetic ophthalmia or Vogt-Koyanagi-Harada disease: Don't judge a book by its cover

Abstract

A 17-year-old female patient of Asian origin presented to the Ocular Immunology Unit of Reggio Emilia Hospital in July 2017, complaining of nausea, vomiting, low-grade fever, tinnitus, and headache going on for 3 days, followed by the appearance of blurred vision in the left eye. Three months before (April 2017) she had a history of penetrating keratoplasty in the right eye for a diagnosis of Acanthamoeba keratitis unresponsive to antiamoebic therapy. The clinical examination exhibited a picture of bilateral panuveitis with papillitis and exudative detachment of the retinal neuroepithelium. The diagnostic workup excluded a possible infectious etiology and showed the positivity of the human leukocyte antigen-DR4. Magnetic resonance imaging showed leptomeningeal inflammatory involvement and lumbar puncture revealed lymphocytic pleocytosis. Considering the history of trauma, Vogt-Koyanagi-Harada disease was ruled out and the diagnosis of sympathetic ophthalmia was made. The patient was treated with topical and oral steroids combined with mycophenolate mofetil for long-term control of the disease. The subsequent 18-month follow-up showed an excellent clinical response with a marked improvement in the ocular findings.