Tubulointerstitial Nephritis and Uveitis (TINU) Syndrome Sana Khochtali Imen Ksiaa Anis Mahmoud Bechir Jelliti Department of Ophthalmology Fattouma Bourguiba.

Tubulointerstitial Tubulointerstitial NephritisNephritis

and Uveitis (TINU) and Uveitis (TINU) SyndromeSyndromeSana KhochtaliSana KhochtaliImen KsiaaImen Ksiaa

Anis MahmoudAnis MahmoudBechir Jelliti Bechir Jelliti

Department of Ophthalmology Department of Ophthalmology Fattouma Bourguiba University Hospital Fattouma Bourguiba University Hospital

Faculty of Medicine, University of Monastir, Faculty of Medicine, University of Monastir, Monastir, TunisiaMonastir, Tunisia

Ocular History - First Ocular History - First PresentationPresentation

15-year-old girl 15-year-old girl OS : photophobia and tearing since OS : photophobia and tearing since

10 days10 days Improvement of symptoms with Improvement of symptoms with

topical steroids given by the parents topical steroids given by the parents Then also vision blurring, redness Then also vision blurring, redness

and photophobia of the OD and photophobia of the OD

June 2012 – First June 2012 – First PresentationPresentation

Visual acuity 20/50 OD, 20/40 OSVisual acuity 20/50 OD, 20/40 OS Intraocular pressure : 19 mmHg Intraocular pressure : 19 mmHg

OD, 16 mmHg OSOD, 16 mmHg OS No vitreous or vitreous haze OSNo vitreous or vitreous haze OS Fundus examination : Fundus examination :

unremarkable OSunremarkable OS

OD granulomatous anterior uveitis with fibrinous exudate in the anterior chamber

OS mild non –granulomatous anterior uveitis with extensive posterior synechiae

Work-up Work-up Chest X-ray : unremarkableChest X-ray : unremarkable Tuberculin-skin test : negativeTuberculin-skin test : negative Blood cell count : WBC count : 7700/mmBlood cell count : WBC count : 7700/mm33

Hb = 11 g/dlHb = 11 g/dl Syphilis serology : negativeSyphilis serology : negative Anti-nuclear antibodies and anti-streptolysine Anti-nuclear antibodies and anti-streptolysine

O antibodies : negativeO antibodies : negative HLA B27 typing : negativeHLA B27 typing : negative

First DiagnosisFirst Diagnosis

Idiopathic anterior uveitis

Treatment: intensive steroid drops and ointment at bedtime (with progressive tapering), as well as mydriatics

fever, malaise, fever, malaise, anorexia and diffuse arthralgiaanorexia and diffuse arthralgia Work-up: renal insufficiency and proteinuria Work-up: renal insufficiency and proteinuria Renal biopsy: acute tubulointerstitial nephritis Renal biopsy: acute tubulointerstitial nephritis Ophthalmological examination: Ophthalmological examination:

no clinical signs of active uveitisno clinical signs of active uveitis Laser flare values : 50 ph/ms OD and 46 Laser flare values : 50 ph/ms OD and 46

ph/ms OSph/ms OS

Follow up - Six weeks later Follow up - Six weeks later

Final diagnosis Final diagnosis

Tubulointerstitial Nephritis Tubulointerstitial Nephritis and Uveitisand Uveitis

(TINU) Syndrome(TINU) Syndrome

systemic prednisolone systemic prednisolone (starting dose of 1 mg/kg/day) (starting dose of 1 mg/kg/day)

maintained for 3 monthsmaintained for 3 months

Slit-lamp photographs show posterior synechiae , that are more prominent in the left eye

Follow-up Follow-up

Recovery of the renal functionRecovery of the renal function Visual acuity : 20/25 OD and 20/32 OS, flare within Visual acuity : 20/25 OD and 20/32 OS, flare within

normal limits normal limits

Four months after TINU syndrome diagnosis,

ConclusionsConclusions Although TINU syndrome is a rare cause of uveitis, it Although TINU syndrome is a rare cause of uveitis, it

should be highly suspected in patients with should be highly suspected in patients with bilateralbilateral anterior uveitis of sudden onset who are younger anterior uveitis of sudden onset who are younger than 20 years. than 20 years.

Urinalysis should be performed in such patientsUrinalysis should be performed in such patients

Uveitis may Uveitis may occur at the same time of, before or after occur at the same time of, before or after nephritisnephritis

ConclusionsConclusions Systemic steroids are usually prescribed to treat renal Systemic steroids are usually prescribed to treat renal

disease. However, they may be required to control disease. However, they may be required to control anterior uveitis if unresponsive to topical steroidsanterior uveitis if unresponsive to topical steroids

A close monitoring is helpful for timely detection of A close monitoring is helpful for timely detection of recurrences of ocular inflammation or insidious recurrences of ocular inflammation or insidious chronic anterior uveitischronic anterior uveitis

Posterior synechia are a common complication of Posterior synechia are a common complication of TINU syndrome-associated anterior uveitis TINU syndrome-associated anterior uveitis