A pregnant woman with dyspnoea, fever & decreased vision

A 30-year old pregnant female presented in the Department of Pulmonary Medicine at Government Medical College, Chandigarh, India, with fever (38.6°C), shortness of breath on exertion, and cough with scanty expectoration since 6 weeks. She was having blurred vision and photophobia in both eyes since preceding two weeks. The physical examination revealed tachypnoea and tachycardia. At the onset of symptoms, patient was 12 weeks pregnant. Baseline routine investigations and arterial blood gas analysis were normal. Chest radiograph was suggestive of classical bilateral miliary shadows (Fig. A). Obstetrical ultrasound at the time of presentation showed a single foetus with mild intrauterine growth restriction. Ophthalmoscopic examination revealed active choroidal lesion (Fig. B).

Fig. 1.

(A) Chest radiograph showing bilateral, diffuse small lung nodules suggesting miliary tuberculosis. (B) Fundus photograph of left eye showing yellowish white, active choroidal lesion (thick arrow) with hazy margins along inferior arcade and elevated foveolar lesion (thin arrow) suggestive of neurosensory detachment of retina (secondary to active choroidal lesion). (C) Fundus montage of left eye showing whitish, healed choroidal lesion (arrow) with discrete margins 6 months post treatment. (D) Chest radiograph showing complete resolution of miliary shadow.

She was treated with isoniazid, rifampicin, pyrazinamide and ethambutol for two months and followed by isoniazid and rifampicin for four months (Category 1 DOTS under Revised National TB Control Programme, RNTCP). She was monitored regularly for the chest condition, the choroid lesions in the eye and foetal outcomes. Her pregnancy was continued and the follow up revealed clinical improvement with resolution of all the symptoms, healing of choroid lesions (Fig. C). The patient delivered a healthy child at term. Chest radiograph after the delivery of the child revealed complete resolution of the miliary lesions (Fig. D).