Correspondence
Rifabutin and Uveitis
N Engl J Med 1994; 330:868March 24, 1994
- Article
To the Editor:
We report two cases of uveitis associated with rifabutin therapy. A 52-year-old woman with pulmonary Mycobacterium avium complex infection who was negative for the human immunodeficiency virus was referred to our clinic in October 1992 after being treated with several antimicrobial regimens without improvement. With a regimen of clarithromycin, ethambutol, and rifampin, fever and night sweats resolved and cough and dyspnea improved greatly. In May 1993 the patient's respiratory symptoms worsened, and on June 10, 1993, rifampin was discontinued and treatment with rifabutin at a daily dose of 600 mg was initiated. Because of low-grade fever, ciprofloxacin was added to the regimen on July 2 but was stopped six days later because of the development of oral ulcers. The oral ulcers resolved, but on July 17 the patient noted a pruritic, erythematous rash on her upper extremities and blurred vision and pain in her right eye. By July 22, the left eye was also involved, and an ophthalmologic examination revealed bilateral anterior uveitis. The patient denied having arthralgias or genitourinary symptoms, but said she had had a similar rash in 1989 during treatment with a regimen that included rifabutin. A rapid plasma reagin test was nonreactive, and a chest film showed no changes. Rifabutin was discontinued, and the uveitis was treated with topical prednisone and scopolamine. The uveitis resolved within a couple of weeks and had not recurred after four months.
A 38-year-old man with the acquired immunodeficiency syndrome (AIDS) who was receiving didanosine and co-trimoxazole started treatment with foscarnet for cytomegalovirus retinitis in May 1993, with a good response. In June 1993 clarithromycin and ethambutol were initiated for M. avium complex bacteremia; rifabutin, at a dose of 600 mg daily, was added on August 5. On August 20 a routine ophthalmologic follow-up examination revealed minimal stable residual retinitis. On September 30, the patient was seen because of a three-day history of blurred vision and eye pain, and bilateral anterior and left posterior uveitis was diagnosed. There was no evidence of worsening cytomegalovirus retinitis, toxoplasma chorioretinitis, arthritis, urethritis, rash, or oral lesions. A rapid plasma reagin test, a lumbar puncture, and cultures of blood, urine, and cerebrospinal fluid for bacteria, fungi, mycobacteria, and viruses were negative; a computed tomographic scan of the head revealed no abnormalities. Rifabutin was discontinued, and uveitis was treated with topical prednisone and scopolamine. The condition resolved over the next few weeks and had not recurred after two months of follow-up.
Rifabutin therapy was associated with uveitis in two patients in a dose-escalation study in which the condition developed when daily doses of 1200 and 1800 mg of rifabutin were given1. Although we cannot be certain that rifabutin caused the uveitis in our patients, the timing of the condition, the lack of other causes, and the fact that uveitis resolved without recurrence after rifabutin was discontinued all suggest it. These cases arouse concern that rifabutin may cause uveitis at lower doses than previously reported. With the increasing use of rifabutin for prophylaxis and treatment of M. avium complex infection in patients with AIDS,2,3 clinicians should be alert to this problem.
3 ReferencesMichael O. Frank, M.D.
Mary Beth Graham, M.D.
Brian Wispelway, M.D.
University of Virginia Medical Center, Charlottesville, VA 229081
Siegal FP ,Eilbott D ,Burger H , et al. Dose-limiting toxicity of rifabutin in AIDS-related complex: syndrome of arthralgia/arthritis. AIDS 1990;4:433-441
CrossRef | Web of Science | Medline2
Nightingale SD ,Cameron W ,Gordin FM , et al. Two controlled trials of rifabutin prophylaxis against Mycobacterium avium complex infection in AIDS. N Engl J Med 1993;329:828-833
Full Text | Web of Science | Medline3
Masur H, Public Health Service Task Force on Prophylaxis and Therapy for Mycobacterium avium Complex
Full Text | Web of Science | Medline
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Levent Akduman, Lucian V. Del Priore, H. J. Kaplan, William G. Powderly. (1996) Rifabutin Induced Vitritis in AIDS Patients. Ocular Immunology and Inflammation 4:4, 219-224
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Thierry Zenone, André Boibieux, Jacques Fleury, Gilles Chaumentin, Fathia Daoud, Christine Burgat, Dominique Peyramond, Jean-Louis Bertrand. (1996) Recurrent Bilateral Anterior Uveitis with Hypopyon and Rifabutin Therapy. Scandinavian Journal of Infectious Diseases 28:3, 325-326
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Elizabeth Eccles, Judy Ptak. (1995) Mycobacterium avium complex infection in AIDS: Clinical features, treatment, and prevention. Journal of the Association of Nurses in AIDS care 6:5, 37-47
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