Endogenous endophthalmitis by Propionibacterium acnes associated with leflunomide and adalimumab therapy

PURPOSE. To report a case of unusual endogenous endophthalmitis associated with the use of leflunomide and adalimumab. METHODS. A 48-year-old woman on treatment with leflunomide and adalimumab for rheumatoid arthritis developed an endogenous endophthalmitis caused by Propionibacterium acnes. Diagnosis was confirmed by polymerase chain reaction and positive cultures. The patient underwent surgical treatment and intravitreal vancomycin, but the eye developed retinal fibrosis and untreatable retinal detachment. RESULTS. This report of endogenous endophthalmitis associated with the use of anti-tumor necrosis factor alpha (anti-TNF-alpha) drugs is consistent with those in the literature. P. acnes may induce pathologic reactions in compromised patients and cause endophthalmitis, but only after ocular surgery or in intravenous drug users. The Naranjo probability scale indicated a probable relationship between the drugs and the infection. CONCLUSIONS. Awareness of atypical infectious conditions in patients on anti-TNF-alpha drugs is critical for early diagnosis and good outcome.