A Mass in the Eye

In July, 2000, a 30-year-old Ghambian man was referred to the hospital by his general practitioner, whom he had consulted 2 weeks earlier, for progressive loss of vision in the right eye over the preceding 8 weeks. On questioning, he also reported malaise, drenching night sweats, and a 5 kg weight-loss during the last 6 months. He had not taken his temperature and had no other symptoms. He had no other known medical problems, and had immigrated to Germany 5 years previously. On examination, the patient was blind in the right eye, with obvious proptosis and panophthalmitis. Visual acuity was normal in the left eye. On fundoscopy of the right eye we found a clear lens and a normal iris; the vitreous contained a haemorrhagic mass, and we could not get a clear view of the fundus. The patient had palpable cervical and axillary lymphadenopathy. Blood tests showed increased transaminases: AST (59 U/L) and ALT (58 U/L), C-reactive protein was 65 mg/L. A complete blood count was normal. Serological tests showed evidence of a chronic hepatitis B infection (surface antigen and core antibodies positive, surface antibodies negative), and no evidence of HIV infection. A tuberculin skin test was positive, but a chest radiograph showed no abnormalities. Cerebral magnetic resonance imaging showed a hyperintense lesion with ring enhancement in the right orbit, a parieto-occipital lesion of the right lobe, and two smaller lesions of the left frontal lobe. Abdominal computed tomography and ultrasonography showed enlarged lymph nodes along the aorta, inferior vena cava, portal and mesenteric veins.