Recurrent Episcleritis Revealing Pulmonary Tuberculosis in an Adolescent: A Case Report and Literature Review

Abstract

Introduction

Tuberculosis (TB) can affect the eye through direct infection or immune mechanisms. While ocular TB most often presents as uveitis or scleritis, episcleritis is an uncommon manifestation and can be mistaken for an idiopathic or autoimmune disease.

Case Presentations

A 17-year-old female patient presented at our hospital with recurrent episcleritis. The first two flare-ups were mild and responded well to conservative treatment; therefore, no further investigation was pursued at the time. However, during the third episode, routine baseline workup revealed a mildly elevated erythrocyte sedimentation rate with a normal chest radiograph (CXR). Given recurrence and a presumed immune-mediated process, she received topical steroids and low-dose methotrexate. Weeks later, she began experiencing fever and a persistent cough. On repeat CXR showed new left upper-lobe changes prompting computed tomography that revealed cavitary lesions. Bronchoalveolar lavage confirmed Mycobacterium tuberculosis. She was promptly switched to standard anti-tubercular therapy showing systemic improvement, and without exhibiting additional episcleritis episodes.

Conclusion

In TB-endemic settings, recurrent episcleritis warrants evaluation for TB before initiating or escalating immunosuppression. New systemic symptoms should prompt repeat chest imaging and microbiologic testing.

Introduction

Tuberculosis (TB) continues to be a global health concern, responsible for high rates of illness and death, especially in developing countries. Ocular TB is rare, occurring in approximately 1–2% of extrapulmonary TB [1, 2]. Robustly corroborated by the WHO Global Tuberculosis Report 2024 (October 2024), TB persists as a severe global public health emergency: in 2023, an estimated 10.8 million people (95% uncertainty interval: 10.1–11.7 million) fell ill with TB, and 1.25 million deaths (95% uncertainty interval: 1.13–1.37 million) were attributed to the disease, reaffirming its position as the world’s leading infectious cause of mortality [3]. When it occurs, it usually presents as uveitis, scleritis, or choroiditis [4, 5]. Episcleritis, by contrast, is mostly self-limited and often linked to autoimmune conditions but it can be infectious [6]. TB causing episcleritis is uncommon and has only been described in a few reported cases [7]. Therefore, diagnosis is challenging due to overlapping features with autoimmune disease and the difficulty of obtaining ocular tissue for microbiological confirmation [8].

Case Presentation

A 17-year-old female had been dealing with repeated episodes of redness and discomfort in her left eye for nearly 9 months. She had no other health issues and did not report any systemic symptoms early on. On examination, best-corrected visual acuity was 20/20 in both eyes (OU) and intraocular pressure was 15 and 16 mm Hg on the right eye and on the left eye, respectively. Focal episcleral inflammation blanched following instillation of one drop of 2.5% phenylephrine, with blanching observed after approximately 5 min of contact time, confirming the superficial vascular involvement consistent with episcleritis, without deep scleral tenderness or anterior chamber reaction, supporting episcleritis rather than scleritis.

• Episodes 1–2 were sectoral, non-nodular, left eye, resolving with lubricants/observation

• Episode 3 remained sectoral and nodular with blanching to 2.5% phenylephrine

• Methotrexate was commenced at 5 mg weekly orally with folic acid 5 mg once weekly

• Episode 4 remained sectoral and nodular

• Following initiation of anti-tubercular therapy, ocular inflammation did not recur over 6 months

Initially, the first two episodes were treated conservatively. The inflammation kept coming back and after the third episode, she was referred to a rheumatologist, thinking it was autoimmune. Pre-immunosuppression investigations (ESR/CRP, CBC, ANA, RF, urate) were unremarkable except for an elevated ESR (40/60 mm/h). The chest radiograph (CXR) was normal. Given the recurrent course and presumed immune-mediated inflammation, treatment was started with topical prednisolone acetate 1% QID (topical) and low-dose methotrexate 5 mg/week orally with folic acid 5 mg/week for presumed immune-mediated episcleritis.

After several weeks into treatment, the patient developed fever and dry cough. These new systemic symptoms prompted repeat imaging. A repeated CXR revealed left upper-to-mid-zone air-space opacities (Fig. 1), and computed tomography confirmed cavitary lesions (Fig. 2). A bronchoscopy was performed, and the lavage fluid tested positive for M. tuberculosis.

Fig. 1.

Repeated chest X-ray: left upper-to-mid-zone air-space opacities.

Fig. 2.

CT scan confirmed cavitary lesions in her lungs.

Pulmonary TB was confirmed, and the episcleritis was considered a likely ocular manifestation of TB. Anti-tubercular therapy (ATT) was initiated with a standard regimen: isoniazid, rifampicin, pyrazinamide, and ethambutol for 8 weeks, followed by isoniazid and rifampicin for a further 16 weeks (total 6 months). Dosing was weight based; the patient received isoniazid 300 mg once daily, rifampicin 600 mg once daily (throughout), and during the intensive phase, pyrazinamide 1,500 mg once daily and ethambutol 1,200 mg once daily. Systemic symptoms resolved, and there were no recurrences of episcleritis over 6 months of follow-up (Fig. 3).

Fig. 3.

Clinical timeline of the progression of the case.

Discussion

Episcleritis is usually a mild, short-lived inflammation that does not point to anything serious [1, 6]. When it keeps recurring, doctors might think of autoimmune diseases such as rheumatoid arthritis, systemic lupus erythematosus, and inflammatory bowel disease [9]. Other infectious causes are rare; TB has been reported in a few cases [4, 5].

Ocular TB can present in many ways, including inflammation in the front or back of the eye, choroidal tubercles, retinal vasculitis, and scleritis [4, 10]. It can result from either direct bacterial invasion or an immune reaction to the bacteria [4, 8]. Direct ocular microbiology is rarely obtained because biopsy carries risk, limiting definitive evidence.

Diagnosing TB-related episcleritis is, therefore, mostly a process of elimination, supported by indirect evidence, skin tests, imaging, and how the patient responds to TB treatment [8, 10]. However, those tests have their flaws. Skin tests can be positive from past BCG vaccination, and Interferon-Gamma Release Assay tests (IGRA) cannot really tell the difference between active and latent TB [8]. What helped confirm the diagnosis in our case was the bronchoalveolar lavage which is a solid, microbiological confirmation of TB infection.

Treating ocular TB can be controversial due to limited research, but the standard approach is to follow standard systemic treatment guidelines. Standard systemic ATT is recommended when there is supportive clinical or microbiological evidence [4, 8, 10]. Usually a combination of 4 drugs for 2 months, followed by two drugs for at least four more [11]. Some cases benefit from corticosteroids, especially when inflammation is severe or driven by immune reactions [4].

An important learning point from this case is the potential harm of using immunosuppressant at an early stage. Treating presumed autoimmune episcleritis with steroids and methotrexate likely made the TB worse before the correct diagnosis was made [10]. This case is a good reminder to always look for infection, especially TB, before starting immunosuppressants in patients with unexplained or recurrent eye inflammation, especially if they are in TB-prone regions.

To our knowledge, few cases have reported episcleritis associated with TB [7]. What makes our case unique is the clear confirmation of active pulmonary TB, adding rare but valuable insight into how TB can show up in the eye. Prior reports typically lacked microbiologically confirmed pulmonary disease; Table 1 summarizes recent TB-associated episcleritis cases for context.

Table 1.

Tubercular episcleritis: selected case reports (last 10–15 years)

Year	Age/sex	TB status	Diagnostic tests	Episcleritis type	Treatment	Outcome	Citation
2015	30/M	Latent/presumed ocular TB (no pulmonary disease on CXR)	TST 15 × 12 mm (+); CXR normal; sputum AFB −; IGRA NR; PCR NR	Nodular (medial and lateral)	Standard ATT (Cat-I: 2HRZE + 4HR); lubricants; topical steroids avoided	Symptoms improved on ATT; doing well at transfer; no flare reported during follow-up	[12]
2021	37/M	Latent (QuantiFERON +; PPD ≈30 mm; CXR negative)	IGRA +; TST/PPD strong +; CXR normal; other labs WNL	Simple, recurrent (same eye)	ATT: 2 months HRZE → 7 months HR; initial topical steroid + oral NSAID	Resolution on ATT; no recurrences over 12 months after completion	[13]
2021	12/F	Latent evidence (IGRA +; strong Mantoux); pulmonary status NR	TST strong +; IGRA (Tuberculin Gold) +; others NR	Nodular	ATT + topical steroid	No relapse at 1-year follow-up	[14]
2016	33/F	Latent (clinical + high Mantoux)	TST highly +; other tests NR	Nodular (recurrent)	ATT (regimen not fully specified)	Recovered well; no recurrence on follow-up	[15]
2012	12/M	Active extrapulmonary (cervical lymph node on FNAC)	FNAC cervical node (+) for TB; other tests NR	Nodular	ATT	Complete resolution after ATT	[16]
2022	16/M	Active pulmonary TB (on ATT)	Radiology consistent with pulmonary TB; phenylephrine test + (blanching); TST/IGRA NR	Nodular, bilateral (superior)	Continue ATT (HR) + topical steroids (fluorometholone → prednisolone) + artificial tears	Complete clinical resolution by 5 weeks	[16]
2025 (early online 2024)	19/M	Active disseminated TB (multiorgan involvement)	Systemic workup confirming disseminated TB; ocular details include nodular episcleritis; specific ocular tests NR	Nodular (with multifocal choroiditis)	Systemic ATT±corticosteroids (per standard neuro-TB practice; article abstract does not detail regimen)	Clinical improvement reported; detailed ophthalmic outcome NR	[17]

Selected reports of TB-associated episcleritis from the last 10–15 years, summarizing age, TB status, diagnostics, episcleritis type, treatment, and outcomes.

ATT, anti-tubercular therapy; HRZE, isoniazid, rifampicin, pyrazinamide, ethambutol; HR, isoniazid + rifampicin; NR, not reported.

Conclusion

Tubercular episcleritis is rare but clinically important, particularly with recurrent disease or systemic red flags. Early microbiologic evaluation and timely ATT can prevent harm from unnecessary immunosuppression; in our case, no episcleritis recurred over 6 months of follow-up.

Acknowledgments

This work was conducted under the guidance and framework of the SRs organization, and we are grateful for their contribution to the coordination and resources that helped make this study possible.

Statement of Ethics

This case report adhered to the tenets of the Declaration of Helsinki. Ethical approval was not required for this single-patient case report in accordance with the policy of Al-Razi Hospital, Ministry of Health, Aleppo, Syria. Written informed consent for publication of the clinical details and images was obtained from the patient’s parent. This case report has been prepared in accordance with the CARE guidelines; the completed CARE checklist is available as supplementary material (for all online suppl. material, see https://doi.org/10.1159/000549763).

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author Contributions

Ali Taghi: conception of the work, acquisition of clinical data, literature review, preparation of Table 1 and Figure 3 (timeline), drafting of the manuscript, and critical revisions. Aya Alayyoubi: data curation, patient follow-up, acquisition/description of slit-lamp findings, assistance with literature table, and manuscript editing. Ahmad Alhamid: clinical investigation, documentation of episcleritis phenylephrine-blanching and ocular exam metrics, contribution to Case Presentation, and manuscript editing. Mohammad Atia: imaging coordination, description and annotation of CXR/CT findings, figure legends, and manuscript review. Elham Tourjoman: laboratory coordination, documentation of BAL microbiology, verification of systemic workup, and manuscript review. Nabhan Alnabhan: data verification, reference management and formatting, and critical reading of the Discussion and Conclusions. Taghreed Touma: patient consent process, drafting of Statement of Ethics and declarations, and language/formatting edits. Ahmad Zein: senior author and supervising specialist, oversight of clinical management and diagnostic strategy, study conception and design, critical revision for important intellectual content, and final approval of the version to be submitted.

Funding Statement

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data Availability Statement

No datasets were generated or analyzed beyond the patient’s medical record. De-identified data underlying this case are not publicly available due to privacy considerations but are available from the corresponding author on reasonable request.