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A 31-year-old African-American woman was referred for a one-year history of worsening vision in both eyes associated with pressurelike pain and photophobia. Her corneas were notable for 4+ “mutton-fat” granulomatous keratic precipitates diffusely distributed in the right eye (see image) and 2+ similar findings in the left. Koeppe and Busacca iris nodules were also noted in both eyes. The vitreous contained 2+ active inflammatory cells in both eyes but peripheral inflammatory snowballs were noted only in the right.
The patient had been diagnosed with optic neuritis 10 years prior and subsequent workup led to a diagnosis of multiple sclerosis, which was controlled on Copaxone (glatiramer acetate). While bilateral granulomatous panuveitis has been associated with MS, we decided to proceed with a sarcoidosis workup. Initial lab data revealed a mildly elevated serum level of lysozyme (21 µg/ml), but angiotensin-converting enzyme levels were normal, and a CT scan of the chest did not reveal hilar adenopathy.
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