There was no associated pain, redness, or floaters

There was no associated pain, redness, or floaters. PORN was first described in a human-immunodeficiency virus (HIV) positive patient in 1990, cases have been reported in HIV-negative patients treated with immunosuppressive therapies as well.[3] Rituximab is a B-cell-depleting anti-CD20 monoclonal antibody that is increasingly being used to treat autoimmune disorders and B-cell non-Hodgkin lymphoma.[4,5] The rituximab versus cyclophosphamide for induction of remission in antineutrophil cytoplasmic antibody-associated vasculitis (RAVE) trial E3 ligase Ligand 9 strongly supports rituximab as an alternative/adjunct to cyclophosphamide for the treatment of relapse of microscopic polyangiitis (MPA).[6] As with other immunosuppressive agents, there is a risk of opportunistic infections, including herpes viruses.[7,8] Schuler em et al /em . reported a case of ARN in a patient of rheumatoid arthritis with scleromalacia following rituximab therapy.[9] We report a potential association between use of rituximab and cyclophosphamide in a patient of MPA and development of PORN. Case Report A 52-year-old Indian female presented with profound diminution of vision in both eyes of 2-week duration. She was a known case of MPA for the last 3 years. Her anti-nuclear antibody and anti-myeloperoxidase antibody were Cav1 positive and renal biopsy showed pauci-immune chronic glomerulonephritis. She was treated with cyclophosphamide infusion 900 mg for 10 monthly pulses followed by oral azathioprine 150 mg once a day and tapering doses of oral prednisolone with good response. She had a relapse 2 months before her ocular complaints for which she received rituximab infusion 1 g followed by 2nd cycle, 2 weeks later. One month post-2nd cycle of rituximab patient developed diminution of vision in the right eye (RE) first followed by left eye, a week later. On presentation to us, her best corrected visual acuity (BCVA) was no light perception in the RE and 20/200 in the left eye. There was no associated pain, redness, or floaters. Anterior segment examination showed a relative afferent pupillary defect in the RE with quiet anterior chamber in both eyes. E3 ligase Ligand 9 Fundus examination revealed grade 1 media clarity, multiple whitish creamy lesions with ill-defined margins involving the E3 ligase Ligand 9 peripheral and outer retina with absence of any vitreous inflammation in both the eyes with disc pallor in the RE [Fig. 1]. In view of necrotizing retinal lesions involving peripheral and outer retina a working diagnosis of herpes virus induced PORN was made and the patient was admitted. She was started on intravenous acyclovir 750 mg three times a day along with oral aspirin 150 mg once a day. Oral azathioprine 150 mg OD was continued and rituximab was stopped, after consultation with a rheumatologist. Low-dose oral steroids (0.5 mg/kg body E3 ligase Ligand 9 weight) were added 2 days after starting acyclovir. Open in a separate window Figure 1 Fundus pictures of both eyes at presentation showing multiple whitish creamy lesions with ill-defined margins involving the peripheral, mid peripheral and outer retina while sparing the retinal vessels. Right eye shows temporal disc pallor and left eye shows a healthy disc (a and b) Laboratory investigations revealed leucopenia with mild anemia. Serum IgG was positive for both cytomegalovirus (CMV) and herpes simplex virus (HSV), while other investigations were normal, including IgM for CMV and HSV. The patient was continued on intravenous acyclovir; however, there was deterioration in the left eye. Left eye BCVA decreased to 1/60 with increase in number of retinitis lesions along with confluence of lesions in both eyes [Fig. 2]. At this stage, anterior chamber tap was done from the RE and it showed the presence of VZV DNA by polymerase chain reaction [Fig. 3]. Intravitreal ganciclovir (2.0 mg/0.1 ml) was injected in the left eye and systemic acyclovir was continued. After 14 days of systemic acyclovir and 4 intravitreal injections of ganciclovir, the retinitis lesions E3 ligase Ligand 9 in both eyes healed and BCVA in the left eye improved to 3/60. At this juncture, she was started on oral valacyclovir 1 g three times a day and intravenous acyclovir was stopped. Oral steroids were tapered while azathioprine was continued, after consultation with a rheumatologist..

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