Recurrent Granulomatous Panuveitis and Sarcoidosis-Like Reaction Associated with Bruton Tyrosine Kinase Inhibitors in Chronic Lymphocytic Leukemia: Recurrence After Switching from Ibrutinib to Pirtobrutinib

PURPOSE: To describe recurrent granulomatous uveitis associated with Bruton tyrosine kinase inhibitors (BTK inhibitors) in a patient with chronic lymphocytic leukemia (CLL), with systemic findings compatible with a sarcoidosis-like reaction. METHODS: Observational single-patient case report including clinical data, imaging and histopathological evaluation. RESULTS: A 64-year-old man with CLL developed bilateral granulomatous panuveitis eight months after initiation of ibrutinib. Inflammatory episodes recurred despite dose reduction. During treatment with ibrutinib, the patient developed cutaneous lesions at venipuncture and pressure sites; skin biopsies demonstrated non-necrotizing granulomas with suppurative inflammation, suggesting drug-induced granulomatous reaction. Ibrutinib was discontinued. The patient subsequently developed bilateral hilar enlargement on chest imaging. After disease progression, second-line therapy with pirtobrutinib was initiated. Eight days later, a new severe episode of bilateral granulomatous panuveitis occurred, fulfilling five of the seven International Workshop on Ocular Sarcoidosis (IWOS) criteria. Infectious causes were excluded. Inflammation improved with systemic and topical corticosteroids. CONCLUSIONS: The temporal relationship between BTK inhibitor exposure and recurrent granulomatous ocular inflammation, together with recurrence after exposure to a second BTK inhibitor, suggests a sarcoidosis-like reaction potentially related to this drug class and raises the possibility of a class-effect-related immune mechanism.