Peripheral ulcerative keratitis: Challenges in immunosuppressing an immunocompromised patient

Abstract

Introduction: Peripheral ulcerative keratitis (PUK) is an inflammatory condition affecting the peripheral cornea. Although rare, it causes significant morbidity in affected individuals. Several autoimmune disorders are associated with the development of PUK. In an immunocompromised patient, the use of standard treatments may increase the risk of infections.
Patient presentation: A 60-year-old HIV-positive female on long-term antiretroviral therapy, with well-controlled hypertension, presented with a 3-week history of a painful, red, left eye with epiphora. Polyarthritis, saddle nose deformity and a CD4 count of 342 were present and tuberculosis (TB) was suspected but only later confirmed by a positive urine lipoarabinomannan (LAM) test. This delayed the initiation of systemic immunosuppressive therapy, necessitating the concurrent treatment of both a severe autoimmune condition and an active infectious disease.
Management and outcome: Initial treatment included lubricants, topical steroid, topical ciprofloxacin drops and oral doxycycline. Because of the risk of pulmonary TB, systemic steroids were withheld pending the TB investigation results. In collaboration with rheumatology, high-dose oral prednisone was initiated. The right eye, ultimately required surgical intervention with conjunctival resection and amniotic membrane transplantation (AMT). The left eye, progressed and required a Gundersen flap procedure.
Conclusion: This case highlights the critical need for a multidisciplinary approach, the complexities of balancing immunosuppressive therapy with the risk of infection and the potential for significant visual morbidity despite aggressive intervention.
Contribution: This research contributes towards refining the diagnostic and therapeutic strategies for this challenging patient population.