Multifocal Choroiditis with Panuveitis is a rare disease belonging to the group of white dot syndromes. Mostly affecting younger myopic women, it is characterized by anterior chamber and vitreous inflammation alongside macular white lesions that extend from the deep retina to the choroid. The diagnosis is one of exclusion, and implies discarding causes of panuveitis and other white dot syndromes. Most often this entity is treated with glucocorticoids, antimetabolites and T cell inhibitors.
We report the case of an 18 year-old female patient with presumptive diagnosis of Multifocal Choroiditis with Panuveitis who was being treated with topical dexamethasone, oral deflazacort and intravitreal dexamethasone. This combination was temporarily able to control inflammation, but relapse occurred every time steroid dose tapering was attempted. Moreover, depression, headache, significant weight gain and posterior subcapsular cataract occurred as side effects of corticoid use. Azathioprine (4mg/Kg/day) was introduced as a steroid sparing agent, but its association with prednisone did not achieve satisfactory control of inflammation. Azathioprine was switched to methotrexate at maximum tolerated dose (10mg/week) and Adalimumab (40mg every other week, as maintenance dose) was added. This drug combination allowed for an adequate control of symptoms and reduction of steroid use while maintaining an acceptable tolerability.
Although anti-TNF monoclonal antibodies is not a commonly used class of immunosuppressants in Ophthalmology, this case illustrates how it may be a useful weapon in recalcitrant Multifocal Choroiditis with Panuveitis.