Tubulointerstitial Nephritis and Uveitis (TINU) Syndrome Sana Khochtali Imen Ksiaa Anis Mahmoud Bechir Jelliti Department of Ophthalmology Fattouma Bourguiba University Hospital Faculty of Medicine, University of Monastir, Monastir, Tunisia

Ocular History - First Presentation 15-year-old girl 15-year-old girl OS : photophobia and tearing since 10 days OS : photophobia and tearing since 10 days Improvement of symptoms with topical steroids given by the parents Improvement of symptoms with topical steroids given by the parents Then also vision blurring, redness and photophobia of the OD Then also vision blurring, redness and photophobia of the OD

June 2012 – First Presentation Visual acuity 20/50 OD, 20/40 OS Visual acuity 20/50 OD, 20/40 OS Intraocular pressure : 19 mmHg OD, 16 mmHg OS Intraocular pressure : 19 mmHg OD, 16 mmHg OS No vitreous or vitreous haze OS No vitreous or vitreous haze OS Fundus examination : unremarkable OS Fundus examination : unremarkable OS

 OD granulomatous anterior uveitis with fibrinous exudate in the anterior chamber  OS mild non –granulomatous anterior uveitis with extensive posterior synechiae

Work-up Chest X-ray : unremarkable Chest X-ray : unremarkable Tuberculin-skin test : negative Tuberculin-skin test : negative Blood cell count : WBC count : 7700/mm 3 Blood cell count : WBC count : 7700/mm 3 Hb = 11 g/dl Syphilis serology : negative Syphilis serology : negative Anti-nuclear antibodies and anti- streptolysine O antibodies : negative Anti-nuclear antibodies and anti- streptolysine O antibodies : negative HLA B27 typing : negative HLA B27 typing : negative

First Diagnosis  Idiopathic anterior uveitis  Treatment: intensive steroid drops and ointment at bedtime (with progressive tapering), as well as mydriatics

fever, malaise, anorexia and diffuse arthralgia fever, malaise, anorexia 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 uveitis no clinical signs of active uveitis Laser flare values : 50 ph/ms OD and 46 ph/ms OS Laser flare values : 50 ph/ms OD and 46 ph/ms OS Follow up - Six weeks later

Final diagnosis Tubulointerstitial Nephritis and Uveitis (TINU) Syndrome  systemic prednisolone (starting dose of 1 mg/kg/day)  maintained for 3 months

Slit-lamp photographs show posterior synechiae, that are more prominent in the left eyeFollow-up Recovery of the renal function Recovery of the renal function Visual acuity : 20/25 OD and 20/32 OS, flare within normal limits Visual acuity : 20/25 OD and 20/32 OS, flare within normal limits Four months after TINU syndrome diagnosis,

Conclusions Although TINU syndrome is a rare cause of uveitis, it should be highly suspected in patients with bilateral anterior uveitis of sudden onset who are younger than 20 years. Although TINU syndrome is a rare cause of uveitis, it should be highly suspected in patients with bilateral anterior uveitis of sudden onset who are younger than 20 years. Urinalysis should be performed in such patients Urinalysis should be performed in such patients Uveitis may occur at the same time of, before or after nephritis Uveitis may occur at the same time of, before or after nephritis

Conclusions Systemic steroids are usually prescribed to treat renal disease. However, they may be required to control anterior uveitis if unresponsive to topical steroids Systemic steroids are usually prescribed to treat renal disease. However, they may be required to control anterior uveitis if unresponsive to topical steroids A close monitoring is helpful for timely detection of recurrences of ocular inflammation or insidious chronic anterior uveitis A close monitoring is helpful for timely detection of recurrences of ocular inflammation or insidious chronic anterior uveitis Posterior synechia are a common complication of TINU syndrome-associated anterior uveitis Posterior synechia are a common complication of TINU syndrome-associated anterior uveitis