Random conjunctival biopsy in multiorgan disease

A previously fit and well 43-year-old woman from West Africa presented with a 9 month history of productive cough, weight loss and unsteadiness on her feet. She denied night sweats. On examination she was apyrexial. Blood cultures were negative. Full blood count was normal, serum ACE was elevated at 194, and she was hypercalcaemic with a low parathyroid hormone level. She was HIV negative. Chest X-ray and subsequent CT chest showed bilateral hilar and mediastinal lymph node enlargement. MRI brain and spine were normal. Lumbar puncture revealed no organisms, low protein and glucose. On further questioning she gave a several months’ history of bilateral blurred vision. She was reviewed by ophthalmology and was found to have visual acuity of 6/9 and mild anterior chamber activity with mutton-fat keratic precipitates …