A 27-year-old female with a history of blurring of vision in both eyes, redness, and pain in the left eye for 7 days and malaise. Her vision was 6/24 in the right eye (OD) and 6/9 in the left (OS). There was an inferonasal scleral nodule of size 2*2 mm with adjacent congestion and dilated tortuous episcleral vessels in OS [Fig. 1a]. OD had an inferotemporal well-defined elevated yellowish choroidal mass of 3 disc diameter size around inferotemporal arcade surrounded by subretinal fluid [Fig. 1c]. Fine-needle aspiration cytology of concurrent chest wall swellings (tubercular abscess from axillary lymph nodes) revealed epithelioid granulomas with necrosis and acid-fast bacilli. Axillary lymphadenopathy was also present. Contrast- enhanced computed tomography (CT) of chest was normal. Hemogram revealed mild lymphocytosis, serology for HIV was negative. Mantoux test was positive (14 mm at 72 hours). The patient was started on antitubercular therapy (ATT). Topical steroid drops were also initiated in OS. Oral steroids were started 1 week after starting ATT and were slowly tapered over 10 weeks.
Figure 1.
(a) Left eye at presentation showing the inferonasal scleral nodule of 2*2 mm size with diffuse congestion and dilated tortuous vessels. (b) Left eye 3 months post ATT shows complete resolution of the granuloma leaving a small flat bluish lesion. (c) Fundus image of right eye at presentation shows an inferotemporal well-defined yellowish elevated choroidal mass with surrounding subretinal fluid. (d) Fundus image of right eye 3 months post-ATT shows resolution of the granuloma with choroidal thinning and scar formation. There is also the complete resolution of subretinal fluid
At 3 months follow-up, visual acuity in both eyes was 6/6. OS showed complete resolution of the nodule leaving a small flat bluish area of thinning [Fig. 1b]. OD showed resolution of exudative RD and resolution of the tuberculoma into a flat inactive scar [Fig. 1d].
Discussion
Choroidal[1] and scleral[2] granulomas are well-known manifestations of disseminated tuberculosis. This is a unique case of disseminated tuberculosis affecting the anterior segment of one eye and the posterior segment of the other eye. In this case, the diagnosis of extra-pulmonary tuberculosis was confirmed by histopathology and the granulomatous ocular lesions responded well to ATT. This case highlights the variable presentations of ocular TB in two eyes of the same patient.
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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
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References
- 1.Goel N, Kumar V, Arora S, Ghosh B. Massive choroidal granuloma as the presenting feature of disseminated tuberculosis in immunocompetent patients. Clin Exp Optom. 2018;101:607–10. doi: 10.1111/cxo.12576. [DOI] [PubMed] [Google Scholar]
- 2.Kesen MR, Edward DP, Rao NA, Sugar J, Tessler HH, Goldstein DA. Atypical infectious nodular scleritis. Arch Ophthalmol. 2009;127:1079–80. doi: 10.1001/archophthalmol.2009.197. [DOI] [PubMed] [Google Scholar]