Sympathetic ophthalmia or Vogt–Koyanagi–Harada disease: Don’t judge a book by its cover

A 17-year-old female patient of Asian origin presented to the Ocular Immunology Unit of Reggio Emilia Hospital in July 2017, complaining of nausea, vomiting, low-grade fever, tinnitus, and headache going on for 3 days, followed by the appearance of blurred vision in the left eye. Three months before (April 2017) she had a history of penetrating keratoplasty in the right eye for a diagnosis of Acanthamoeba keratitis unresponsive to antiamoebic therapy. The clinical examination exhibited a picture of bilateral panuveitis with papillitis and exudative detachment of the retinal neuroepithelium. The diagnostic workup excluded a possible infectious etiology and showed the positivity of the human leukocyte antigen-DR4. Magnetic resonance imaging showed leptomeningeal inflammatory involvement and lumbar puncture revealed lymphocytic pleocytosis. Considering the history of trauma, Vogt–Koyanagi–Harada disease was ruled out and the diagnosis of sympathetic ophthalmia was made. The patient was treated with topical and oral steroids combined with mycophenolate mofetil for long-term control of the disease. The subsequent 18-month follow-up showed an excellent clinical response with a marked improvement in the ocular findings.