Presumptive ocular tuberculosis: A case series of rare cases

Abstract

Ocular tuberculosis (TB) may present with various clinical manifestations and may involve any part of the eye. In 80% of cases, pulmonary involvement is not found. Here, we are presenting three cases of presumptive ocular TB with three rare manifestations. The first case is of bilateral retinal detachment involving one eye after another, the second case is of tubercular phlyctenular keratoconjunctivitis with keratolysis, and the third case is of bilateral neuroretinitis with extensive cerebral involvement. Despite the availability of various tests, clinical findings, tuberculin skin test, chest X-ray, and computed tomography of the chest is still the primary basis of diagnosis of ocular TB in the tubercular endemic area, even in rare cases.

Introduction

Tuberculosis (TB) is a multisystem disease. About 80% of cases of ocular TB do not show any pulmonary manifestation. Ocular TB may present with various manifestations ranging from corneal involvement, uveitis, scleritis, serpiginous choroiditis, choroidal granuloma, and retinal detachment (RD) to neuroretinitis.[1] Diagnosis of these cases is usually made on the basis of clinical manifestations, immunological reaction to the tubercular antigen (tuberculin test, tuberculin interferon-gamma release assay), and other supportive evidence in the form of X-ray and computed tomography (CT) chest where we can get an active lesion or a healed lesion. These cases are included under the diagnosis of presumptive ocular TB. Polymerase chain reaction (PCR) test of ocular fluid can be used as supportive evidence, but because of its low sensitivity, TB cannot be ruled out, even though PCR is negative.[2] For diagnosis confirmation biopsy of lymph nodes and sputum examination can be done, which in ocular TB most of the time is not possible.

Here, we are presenting three cases of presumptive ocular TB with rare manifestations. The first case is of bilateral exudative RD with tubercular granuloma. The second case is of phlyctenular keratoconjunctivitis with keratolysis and the third case is of bilateral neuroretinitis with multiple cerebral tuberculoma with extensive cerebral edema.

Case Reports

Case 1

An 18-year-old female was diagnosed with Tubercular serpiginous-like retinochoroiditis in her right eye 2 years back elsewhere. She was on anti-tubercular treatment (ATT), which she discontinued after 5 months. Within 3 months of discontinuation, she presented to us with a sudden diminution of vision in her left eye. The best-corrected visual acuity in her right eye and left eye was 6/24 and hand movement, respectively. No anterior chamber reaction was present in the right eye, while in the left eye, 2 + aqueous cells and minimal flare were present. On fundus examination, in the right eye, healed serpigenous-like choroiditis and in the left eye, exudative RD with large tubercular granuloma was found [Figure 1a and b]. Her optical coherence tomography (OCT) was also showing RD with multifocal choroidal granuloma [Figure 1c]. Serum angiotensin-converting enzyme, venereal disease research laboratory reports were normal. Her Montoux was 15 mm × 20 mm and her erythrocyte sedimentation rate (ESR) was 26 mm. Chest X-ray was normal. CT thorax revealed a few fibrotic bands in the upper lobe of the lung, suggestive of sequelae of some infective pathology.

Figure 1.

An 18-year-old female with bilateral exudative retinal detachment (RD) (a) healed serpiginous-like choroiditis right eye (b) exudative RD with choroidal granuloma (black arrow) left eye (c) optical coherence tomography picture of the left eye with choroidal granuloma and RD (white arrow)

On the basis of clinical findings, positive Montoux and negative reports for other disorders, we diagnosed it as presumptive ocular TB and started on oral steroids and ATT. Although the patient started responding to treatment in the left eye, within 5 months of ATT treatment, she developed exudative RD in the right eye with a large choroidal granuloma involving the inferior part of the disc [Figure 2a and b]. We continued with ATT and started oral steroids again. RD subsided to a great extent within a week, but granuloma took 8 weeks to resolve completely. The steroid was tapered slowly and a very small dose was continued for 6 months. ATT treatment was stopped after 12 months, and now after 3 years of follow-up, we did not find any recurrence.

Figure 2.

Same patient after 5 months (a) exudative retinal detachment in the right eye (b) healed lesion in the left eye

Case 2

An 8-year-old female presented with blurring of vision in her right eye. She had a history of on-and-off fever with loss of appetite and weight loss for the last 1 year and one episode of phlyctenular conjunctivitis 6 months back, which subsided on topical steroids. She has no other systemic history.

On examination, in her right eye, her vision was 6/9p and in her left eye was 6/9. In both eyes, two small corneal opacities were noted. A small 1.5 mm × 1.0 mm area of corneal stromal lysis was present at the level of the superior pupillary margin in the right eye [Figure 3a and b]. Lesion was fluorescein stain negative. There was no conjunctival congestion or pain. Corneal luster and tear film height were normal. Schirmer's test reading was 35 mm. There was no anterior chamber reaction or any eyelid changes in any eye. Anterior segment OCT findings also reveal stromal lysis [Figure 3c]. She developed conjunctival phlycten in the same eye, while her systemic investigation report was still awaited.

Figure 3.

An 8-year-old female with phlyctenular keratoconjunctivitis with small keratolysis (a and b) Right eye with corneal opacities (small arrows) and keratolysis (big arrow) (c) anterior segment optical coherence tomography of the same eye showing stromal lysis (asterix)

We sought investigations for systemic disease with her antinuclear antibody, antineutrophil cytoplasmic antibodies (p-ANCA and c-ANCA), rheumatoid factor came out to be negative. ESR was 30 mm. Her Montoux test was 10 mm × 12 mm and her chest X-ray showed bilateral perihilar congestion.

Diagnosis of tubercular phlyctenular keratoconjunctivitis with keratolysis was made, and she was started on topical steroids and ATT. Her ocular and systemic condition improved in her next visit, but the patient lost to follow-up after that.

Case 3

A 17-year-old female presented with on-and-off episodes of fever for the last 6 months, followed by headache and vomiting for the last 2 months, which was not relieved after local treatment. For the last 3 months, she was complaining of bilateral profound vision loss that increased to total blindness. She was also having a history of amenorrhea for the last 4 months. On examination, there was no perception of light in both eyes with sluggishly reacting pupil. Mild vitritis was present. On fundus examination, both eyes showed extensive disc edema with macular star [Figure 4a and b]. ESR was raised to 35 mm, and Montoux was positive (12 mm × 13 mm). As she could not afford magnetic resonance imaging contrast, she underwent CT brain, which showed multiple cerebral tubercles with extensive edema [Figure 4c]. Blood pressure was 120/70. Chest x-ray was normal.

Figure 4.

A 17-year-old female with bilateral neuroretinitis (a and b) right eye and left eye at presentation (c) computed tomography (CT) brain showing tubercles with extensive edema (white arrow) (d and e) after 1 month right eye and left eye (picture taken from the smartphone) (f) CT after 1 month with resolving edema

On the basis of clinical and CT findings, diagnosis of presumptive ocular TB with both eyes neuroretinitis was made and treatment in the form of ATT along with oral prednisolone was started. The patient showed marked improvement in the disc and retinal swelling along with her cerebral features within 1 month, but the vision did not improve, and optic atrophic changes settled [Figure 4d-f].

Discussion

TB is primarily a disease of the lungs but may affect extrapulmonary organs, including the eye. In the eye, it may affect any structure and may have varied manifestations. Exudative RD and bilateral exudative RD is a rare manifestation of ocular TB. Only five cases of bilateral exudative RD have been reported so far.[3] Our patient responded well to oral steroids along with ATT, signifying the importance of systemic steroids in these cases.

In the second case, we reported a rare manifestation of phlyctenular keratoconjunctivitis with keratolysis. Clinical history and presence of corneal scar of phlyctens, positive Montoux test, X-ray findings, and the absence of eyelid margin changes supported our diagnosis of tubercular origin. Corneal manifestations of TB have been previously reported only in the form of phlyctenulosis and interstitial keratitis.[4,5] In one case series, Arora et al. reported eight cases of corneal perforation manifested as the presenting feature of systemic TB, though not associated with any other ocular findings.[6]

In the third case, features in favor of diagnosis were a history of chronic illness with on and off fever with amenorrhoea, positive Montoux test, cerebral tuberculoma, and rapid response to treatment. The presence of profound vision loss, macular star, and vitreous cells differentiates it from bilateral papilloedema. Davis et al.,[7] in their study, found that a total of 14.5% of patients with tubercular optic neuropathy have neuroretinitis as a presentation though most of the time, these are unilateral.[7]

As the ocular TB may present with various manifestations and may affect any part of the eye, in TB endemic area, we should always remain attentive to clinical clues related to TB. Diagnosis of ocular TB is still presumptive and tuberculin skin tests, chest X-ray and CT chest are the most important supportive investigations for the diagnosis, even in rare cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.