Bilateral interstitial keratitis in a patient with presumed brain tuberculoma / Ceratite intersticial bilateral em um paciente com tuberculoma cerebral presumido

ABSTRACT Interstitial keratitis is an inflammation of the corneal stroma without epithelium or endothelium involvement. The underlying causes are mostly infectious or immune mediated. Brazil has one of the highest incidence rates of tuberculosis in the world. Tuberculosis is considered one of the causes of interstitial keratitis. Malnutrition and anemia are risk factors of the disseminated disease. This is a case report of a 10-year-old child who presented with decreased visual acuity and a clinical diagnosis of bilateral interstitial keratitis and sclero-uveitis. The patient had been treated with topical steroids with partial improvement. Examinations revealed severe iron deficiency anemia, negative serologies for human immunodeficiency virus and syphilis, positivity for cytomegalovirus- and herpes simplex-specific IgG, and purified protein derivative of 17 mm. During the follow-up, the patient presented with tonic-clonic seizures, and magnetic resonance imaging findings suggested a central nervous system tuberculoma. Interstitial keratitis improvement was observed after specific tuberculosis treatment. This is the first case report describing the association of interstitial keratitis and central nervous system tuberculoma.

RESUMO A ceratite intersticial é uma inflamação do estroma corneano sem envolvimento epitelial ou endotelial causada principalmente por doenças infecciosas e imunomediadas. O Brasil tem altas taxas de tuberculose que deve ser lembrada como causa de ceratite intersticial. Desnutrição e anemia são fatores de risco da forma disseminada da tuberculose. Este é um relato de uma criança de 10 anos com redução de acuidade visual e diagnóstico clínico de ceratite intersticial bilateral e esclerouveíte. O paciente obteve melhora parcial da ceratite com corticoide tópico. Exames laboratoriais mostraram anemia ferropriva grave, sorologias negativas para HIV e sífilis; IgM negativo e IgG positivo para citomegalovírus e herpes simplex e PPD positivo (17 mm). Ele evoluiu com crises tônico-clônicas e a ressonância nuclear magnética revelou tuberculoma do sistema nervoso central. A melhora da ceratite intersticial foi observada após tratamento para tuberculose. Este é o primeiro caso que descreve a associação de ceratite intersticial e tuberculoma do sistema nervoso central.

A Series of Ocular Tuberculosis Cases from A Rural Tertiary Care Center in West Bengal

Tuberculosis in Eye can have diverse presentations leads to diagnostic difficulty. If no extra-ocular tubercular lesions are found then it becomes a challenge to diagnose & treat. Here authors present 6 cases of Ocular Tuberculosis without any associated extra-ocular tubercular lesions. One case of tubercular anterior uveitis, eales disease, solitary Choroidal Tuberculoma, bilateral multiple Choroidal Tuberculoma, multifocal & serpiginous like Choroiditis are presented here. All of them were resolved with first line anti-tubercular regimen and corticosteroids. Authors recommend initial visual assessment for all Tuberculosis cases to diagnose & treat hidden cases of Ocular Tuberculosis which may be sight threatening.

A propósito de un caso pediátrico de tuberculosis oftálmica y drogorresistencia / Presentation of a Pediatric Case of Ocular Tuberculosis and Drug Resistance

El compromiso ocular es una forma extrapulmonar de tuberculosis. Puede comprometer cualquier componente del sistema visual. Las manifestaciones oculares pueden ser causadas por una infección activa que invade el ojo o por una reacción inmunológica de hipersensibilidad retardada. Las presentaciones clínicas más comunes son uveítis anterior crónica, coroiditis y esclero-queratitis. A pesar de la existencia de herramientas moleculares altamente sensibles, arribar al diagnóstico de formas poco frecuentes o no pensadas como la TB ocular en un niño sigue siendo un gran reto y se basa en la presentación clínica, evaluación sistémica y la respuesta terapéutica. El tratamiento implica el uso de antifímicos y, muchas veces, esteroides. El objetivo fue presentar una forma de tuberculosis endoftálmica, pulmonar miliar y meníngea, en el marco de la drogorresistencia.

Eye engagement is an extrapulmonary form of tuberculosis. It can compromise any component of the visual system. Eye manifestations can be caused by an active infection that invades the eye or by a delayed hypersensitivity immune reaction. The most com mon clinical presentations are: chronic anterior uveitis, choroiditis and sclero-keratitis. Despite the existence of highly sensitive molecular tools, arriving at diagnosis in rare or undeceived ways with eye tuberculosis in a child remains a major challenge, based on clinical presentation, systemic evaluation and therapeutic response. Treatment involves the use of antiphymics and often steroids. The objective was to present a form of endophthalmic tuberculosis, miliary pulmonary and meningeal, in the framework of drug resistance.

A STUDY OF CLINICAL AND ETIOLOGICAL PATTERN AND SEASONAL VARIATION IN THE INCIDENCE OF ANTERIOR UVEITIS AT A TERTIARY CARE CENTER

Purpose: The aim was to study the various pattern and any seasonal variation in the incidence of anterior uveitis at a tertiary care center. An observational study was conducted on 100 patients of all Methods: new uveitis cases who attended the OPD between January 2020 to December 2021 of a tertiary care center, J.L.N. medical college and hospital, Ajmer, Rajasthan. We grouped the months into winter, autumn, monsoon, spring and summer according to Indian weather. Cases were screened along with detailed clinical and laboratory investigation to ?nd out there clinical etiological causes. 100 Patients of uveitis were examined. There was male predominance (66%) with male to female Result: ratio 1.94:1. We found cases with unilateral (91%) uveitis to be more common, with more Right eye (48%) involvement. Majority (40%) of cases remained idiopathic. HLA-B27 (37%) was commonest association followed by lens induced and Tuberculosis. The incidence of uveitis in winter season (38%) followed by 33% in transitional season and 29% in summer. Non- Conclusion: infectious uveitis were more common. In Non-infectious uveitis, most common entity found to be Idiopathic and HLA-B27 associated whereas in infectious uveitis, ocular tuberculosis was found to be the leading cause. Seasonally uveitis were more in winter and less in summer

Metástasis coroidea como manifestación inicial de adenocarcinoma de pulmón en paciente joven: informe de caso / Choroidal metastasis as an initial manifestation of lung adenocarcinoma in a young patient: case report

Introducción: se presenta el caso de un paciente de 36 años, a quien se le realizó el diagnostico de tuberculoma coroideo, otorgando tratamiento sin mejoría de los síntomas. Posteriormente fallece dilucidándose el diagnóstico de adenocarcinoma de pulmón con metástasis a coroides. Objetivo: informar el diagnóstico de metástasis coroidea como manifestación inicial, de adenocarcinoma de pulmón, en un paciente joven. Diseño de estudio: reporte de caso. Resumen del caso: masculino de 36 años de edad, antecedente de tuberculosis en la infancia, tabaquismo positivo no significativo. Presenta baja visual de ojo derecho, siendo diagnosticado con tuberculoma coroideo, asociado a sudoración nocturna, lumbalgia, tos y QuantiFERON-TB positivo. Se inicia tratamiento antituberculosis. Posterior, presenta deterioro respiratorio y neurológico requiriendo intubación orotraqueal, ulteriormente fallece. La autopsia elucida el diagnóstico de adenocarcinoma de pulmón con metástasis a coroides, hígado y riñón. Conclusión: las metástasis coroideas conllevan un mal pronóstico visual y sistémico, se requiere un alto índice de sospecha en pacientes menores de 50 años sin factores de riesgo. Se convierten en un reto diagnóstico, sobre todo en países donde predominan las enfermedades infecciosas. El papel del oftalmólogo es realizar el diagnóstico oportuno y correcto, evitando así retrasar el tratamiento.

Background: the case of a 36 year-old patient is presented, who was diagnosed with choroidal tuberculoma, giving treatment without improvement. Then, the diagnosis of pulmonary adenocarcinoma and choroidal metastases was elucidated. Objective: to report the diagnosis of metastasis as the initial manifestation of lung adenocarcinoma in a young patient. Study design: case report. Case summary: male, 36 years old, history of tuberculosis in childhood, positive smoking, but not significant. He presented visual loss of the right eye, being diagnosed with a choroidal tuberculoma, associated with night sweats, cough and positive QuantiFERON-TB test, treatment for tuberculosis was initiated. Later he had respiratory and neurological deterioration requiring orotracheal intubation, but unfortunately he died. Autopsy reveals lung adenocarcinoma with choroidal, liver and kidney metastases. Conclusion: choroidal metastases lead to poor visual and systemic prognosis, a high suspicion is required in patients under 50 years of age without risk factors. They become a diagnostic challenge, especially in countries where infectious diseases are predominat. The ophthalmologist's role is to make the diagnosis timely and correctly, thus avoiding delaying treatment.

Aspectos clínicos e tratamento de pacientes com tuberculose ocular presumida em centro de referência de São Paulo, Brasil. Estudo retrospectivo / Clinical description and treatment of patients with presumed ocular tuberculosis in São Paulo, Brazil. Retrospective study

Resumo Objetivo: Descrever aspectos clínicos e esquema terapêutico dos pacientes com tuberculose ocular presumida tratados em um centro de referência em tuberculose de São Paulo. Métodos: Estudo retrospectivo descritivo. O teste exato de Fisher foi realizado quando apropriado. Resultados: A queixa mais comum foi baixa acuidade visual (83,1%), seguida por dor ocular generalizada (25,3%) e visão turva (22,8%). A uveíte posterior foi a apresentação mais comum (35,7%). O tratamento consistiu no esquema atualmente recomendado de rifampicina, isoniazida, pirazinamida e etambutol (RHZE). A prednisona oral foi incluída no tratamento de 37 pacientes, para tratamento da inflamação aguda, embora não tenha diminuído a prevalência de complicações crônicas, em comparação com a recuperação completa (p = 0,1). O diagnóstico precoce (<70 dias) foi associado a maiores taxas de recuperação total (p = 0,005). Não houve significância estatística quando se comparou a terapia de 6 a 9 meses (p = 0,7). Conclusão: A uveíte tuberculosa pode ser tratada por uma terapia com duração de seis meses. Um breve curso de esteroides melhora os sintomas agudos, embora não reduza as complicações a longo prazo.

Abstract Purpose: To analyze and describe the therapy used in presumed ocular tuberculosis in a referral center in São Paulo, Brazil. Methods: Retrospective, descriptive study. Fisher's exact test was performed when appropriate. Results: The most common complaint was low visual acuity (83.1%), followed by generalized ocular pain (25.3%) and blurred vision (22.8%). Posterior uveitis was the most common presentation (35.7%). Treatment consisted of the currently recommended association of rifampin, isoniazid, pyrazinamide, ethambutol (RHZE) regimen. Oral prednisone was included in the treatment of 37 patients for acute inflammation, although it did not significantly decrease the prevalence of chronic complications compared to full recovery (p = 0,1). Early diagnosis (< 70 days) was associated with higher rates of full recovery (p = 0.005). No statistical significance was observed when comparing 6 to 9-month therapy (p = 0.7). Conclusion: Tuberculous uveitis can be treated with a 6-month duration RHZE therapy. A brief course of steroids may improve acute symptoms, although it did not reduce long-term disabilities.

An unusual case of tuberculous optic neuropathy associated with choroiditis

Tuberculous optic neuropathy that includes papillitis, neuroretinitis, and optic nerve tubercle is a rare presentation of ocular tuberculosis. Though contagious spread from choroid following the hematogenous dissemination of the bacilli has been implicated in the optic nerve involvement, unlike neuroretinitis, optic nerve and choroidal involvement are usually considered as two separate clinical entities. We report a case of optic nerve involvement in a 33-year-old male who had concurrent choroidal involvement at present and also in the past. A strong history of contact with patients of pulmonary tuberculosis, positive tuberculin skin test, interferon gamma release assay, and high-resolution computed tomography helped us to clinch the diagnosis. Patients responded to systemic corticosteroid therapy and anti-tuberculosis treatment. Choroidal involvement in a case of inflammatory optic neuropathy should arise suspicion of tuberculous etiology.

Familial Blau syndrome:First molecularly confirmed report from India

Blau syndrome (BS) is a rare autoinflammatory disorder characterized by the clinical triad of arthritis, uveitis, and dermatitis due to heterozygous gain-of-function mutations in the NOD2 gene. BS can mimic juvenile idiopathic arthritis (JIA)-associated uveitis, rheumatoid arthritis, and ocular tuberculosis. We report a family comprising a mother and her two children, all presenting with uveitis and arthritis. A NOD2 mutation was confirmed in all the three patients – the first such molecularly proven case report of familial BS from India.

Loop mediated isothermal amplification assay using hydroxy naphthol blue, conventional polymerase chain reaction and real-time PCR in the diagnosis of intraocular tuberculosis.

This study is a comparative evaluation (Chi-square test) of a closed tube loop mediated isothermal amplification assay using hydroxy naphthol blue dye (HNB-LAMP), real-time polymerase chain reaction (PCR) and conventional PCR in the diagnosis of intraocular tuberculosis. Considering clinical presentation as the gold standard in 33 patients, the sensitivity of HNB-LAMP assay (75.8%) was higher (not significant, P value 0.2) than conventional PCR (57.6%) and lower than real-time PCR (90.9%). Specificity was 100% by all three methods. No amplification was observed in negative controls (n = 20) by all three methods. The cost of the HNB-LAMP assay was Rs. 500.00 and it does not require thermocycler, therefore, it can be used as an alternative to conventional PCR in resource-poor settings.

Tuberculosis extrapulmonar en el niño / Extrapulmonary tuberculosis in children

Pulmonary tuberculosis (TB) is the most common type of TB in children. Extrapulmonary tuberculosis is also prevalent (about 30-40 percent of cases) and it can occur in a variety of anatomical sites. This study presents a review of the literature on the main clinical manifestations of extrapulmonary tuberculosis in children, its diagnosis and treatment. At the end, some reflections on the importance of BCG for prevention are presented.

La tuberculosis (TB) pulmonar es el tipo más común de TB en niños. La tuberculosis extrapulmonar también es frecuente (alrededor de 30-40 por ciento de los casos) y se puede presentar en una gran variedad de sitios anatómicos. Se hace una revisión de la literatura sobre las principales manifestaciones clínicas extrapulmonares de la tuberculosis en niños, su diagnóstico y su tratamiento. Al final se hacen algunas reflexiones sobre la importancia de la BCG para su prevención.

A case of subretinal tubercular abscess presenting as disc edema.

We report a case of ocular tuberculosis (TB) which initially presented with disc edema and was mistaken for optic neuritis. With no definite pathology being identified, the patient was treated on the lines of optic neuritis with intravenous (IV) steroid with beneficial effect. Ocular TB was suspected when he presented later with a subretinal abscess. Based on positive Mantoux, QuantiFERON TB gold results and radiographic findings, a diagnosis of subretinal abscess of presumed tubercular etiology was made. The patient was successfully treated with anti‑tubercular therapy. To the best of our knowledge, this is the first case report of ocular TB presenting as disc edema followed by subretinal abscess.

Clinical characteristic and therapy results of presumed ocular tuberculosis and their relation to HIV status.

Background: Ocular tuberculosis (TB) emerges as an important cause of intraocular inflammation, partly due to the increasing number of HIV/AIDS patients. This study attempts to identify ocular signs that are associated with ocular TB and assess the efficacy of the treatment and their relation to HIV status. Methods: Medical records of all 56 patients diagnosed with presumed ocular TB in Cipto Mangunkusumo Hospital between January 2006 and December 2011 were reviewed. Demographic and clinical characteristics and HIV status were recorded as well as efficacy of treatments given. Results: There were 39 patients included with mean age 35.38 ± 13.1 and male to female ratio was 2:1. Unilateral involvement was in 26 (66.7%) patients. From all, four (10.3%) had anterior uveitis, 14 (35.9%) posterior uveitis, 21 (53.8%) panuveitis, and none had intermediate uveitis. Most of them (32/82.1%) have concurrent other organ TB. Five out of 8 (62.5%) HIV positive patients had granulomatous inflammation and 3 (37.5%) had non-granulomatous inflammation and all eight of them had concurrent other organ TB. The other 7 known non-HIV patients, six (85.7%) have non-granulomatous inflammation. Treatment with anti-tubercular therapy (ATT), combination ATT and steroid or steroid alone increased visual acuity. However steroid alone was slightly have more frequent recurrences (1.4 ± 0.89 episodes of inflammation). Conclusion: Ocular TB in our study had variable clinical manifestations and ocular inflammation was predominantly non-granulomatous in HIV negative patients and granulomatous in HIV infected patients. All HIV positive patients the ocular TB was always accompanied by manifestations in other organs. The treatment with steroids solely resulted in improved vision but was characterized by frequent recurrences.

Successful Visual Outcome Following Vitrectomy for Complication of Ocular Tuberculosis

A 24-year-old Chinese gentleman presented with two weeks history of sudden floaters in his right temporal visual field associated with blurring of vision. This ex-smoker also reported chronic, bloody cough for two years and recent pleuritic chest pain. Examination revealed a thin patient with right eye visual acuity of 6/18 associated with optic nerve dysfunction, optic disc swelling and macula star, retinal vasculitis and retinitis. Despite anti-tuberculosis medication and corticosteroids, he developed neovascularisation. Subsequent vitreous haemorrhage necessitated trans pars plana vitrectomy, membrane peeling, endolaser and silicone oil injection. Final visual acuity was 6/9 with quiescent retinopathy.

Atypical Ocular and Optical Coherence Tomographic Findings With Presumed Miliary Tuberculosis

PURPOSE: To report clinical features and optical coherence tomographic findings of presumed atypical ocular tuberculosis associated with tuberculosis lymphadenitis and encephalomeningitis. CASE SUMMARY: A 28-year-old female with lymphadenitis in the axillary area presented with a fever and headache of a one week duration. CSF study and MRI findings implied tuberculosis encephalomeningitis, and presumed tuberculosis uveitis manifested with visual disturbance after five days. Ocular symptoms were aggravated and showed anterior iridocyclitis, vitritis, macular edema, and multifocal retinitis with miliary granuloma that was distinct from choroiditis or typical tuberculosis granuloma. After the patient received anti-tuberculosis medication and systemic corticosteroids, significant improvements in visual acuity, ocular findings and OCT results were observed. CONCLUSIONS: Ocular tuberculosis can present with various clinical findings, and caution should be taken so as not to misdiagnose based on these characteristics. In the present case, anti-tuberculosis medication and systemic steroids resulted in the resolution of inflammation. In such cases, monitoring the posterior pole lesion via OCT may be helpful in determining improvement.

Current approach in the diagnosis and management of posterior uveitis.

Posterior uveitic entities are varied entities that are infective or non-infective in etiology. They can affect the adjacent structures such as the retina, vitreous, optic nerve head and retinal blood vessels. Thorough clinical evaluation gives a clue to the diagnosis while ancillary investigations and laboratory tests assist in confirming the diagnosis. Newer evolving techniques in the investigations and management have increased the diagnostic yield. In case of diagnostic dilemma, intraocular fluid evaluation for polymerase chain testing for the genome and antibody testing against the causative agent provide greater diagnostic ability.

Tuberculosis ocular / Ocular tuberculosis

Tuberculosis (TB) is considered a public health problem in several countries. This disease is classified as either pulmonary or extrapulmonary. Within the extrapulmonary disease, ocular involvement is uncommon but it is important to recognize it because its incidence has been reported up to 1 percent. Ocular TB cases can be divided in primary and secondary. These manifestations can be caused by an active infection that invades the eye or by an immunologic reaction of delayed hypersensitivity in absence of the infectious agent. The most common clinical presentations are: chronic anterior uveitis, choroiditis and sclerokeratitis. Despite the existence of highly sensitive molecular diagnostic techniques, the diagnosis of ocular tuberculosis continues to be presumptive, based upon clinical presentation, systemic evaluation and response to treatment. For the treatment we use four drugs during a two month period (isoniazid, rifampin, pyrazinamide and ethambutol) and two drugs for four additional months.

La tuberculosis (TBC) es considerada un problema de salud pública en varios países del mundo. Esta enfermedad se clasifica en pulmonar y extra pulmonar. Dentro de la forma extra pulmonar, el compromiso ocular es poco común, pero es importante conocerlo ya que su incidencia puede llegar hasta 1 por ciento. Los casos de TBC ocular se dividen en primarios y secundarios. Las manifestaciones oculares pueden ser causadas por una infección activa que invade el ojo o por una reacción inmunológica de hipersensibilidad retardada, en ausencia del agente infeccioso. Las presentaciones más comunes son: uveítis anterior crónica, coroiditis y esclero-queratitis. A pesar de la existencia de herramientas moleculares altamente sensibles, el diagnóstico de TBC ocular continúa siendo presuntivo, basándose en la presentación clínica, evaluación sistémica y la respuesta terapéutica. Para el tratamiento se utilizan cuatro fármacos por dos meses (isoniacida, rifampicina, pirazinamida y etambutol) y dos fármacos por cuatro meses adicionales.

A Case of Wegener's Granulomatosis Misdiagnosed as Ocular Tuberculosis

PURPOSE: To report a case of Wegener's granulomatosis misdiagnosed as ocular tuberculosis. METHODS: A 65-year-old man who was treated with anti-tuberculosis medications as suspected pulmonary tuberculosis was referred from the department of internal medicine for visual loss over months. His initial visual acuity was counting fingers at 30 cm in the right eye and there was a chorioretinal scar involving the macula on fundus examination. At that time, we thought that the lesion was a tuberculosis-related chorioretinal scar and so he was treated with anti-tuberculosis medications. There was a recurrent bilateral anterior uveitis during three months from the initial visit. RESULTS: After 14 months, he was examined by otorhinolaryngologist due to a saddle nose deformity and Wegener's granulomatosis was diagnosed based on positive Cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) and nasal mucosal biopsy. At that time, ocular examination revealed the necrotizing scleritis in both eyes and orbital CT showed bony destruction of medial and inferior orbital wall without proptosis in both eyes. We had treated with oral cyclophosphamide and prednisone. CONCLUSIONS: We experienced a case of Wegener's granulomatosis with chorioretinal scar misdiagnosed as ocular tuberculosis. In conclusion, we should differentially diagnose Wegener's granulomatosis from suspected ocular tuberculosis.