Pulmonary tuberculosis presenting with central retinal vein occlusion

A rare case of coexistence of Wegener's granulomatosis and pulmonary tuberculosis with subsequent development of thrombosis of the cerebral veins

BACKGROUND

Granulomatosis with polyangiitis (GPA), also known as Wegener's granulomatosis, is an idiopathic systemic disease typically affecting the lungs, although other organs may also be involved.

CASE PRESENTATION

A 28-year-old male was admitted to Baqiyatallah university hospital in Teheran (Iran) after a 3-week history of fever and productive cough. The patient gradually developed fatigue, arthralgia, hematuria, nausea, vomiting, dyspnea, hemoptysis, weight loss, oliguria and then anuria. Chest-X-ray (CXR) and computerized tomography scan revealed cavitating nodular opacities in the right lung lobe. Furthermore, plasma creatinine increased from 2.2 to 4 mg/dl in a few days. Histopathological examination of kidney biopsy revealed peri-glomerular and peri-vascular inflammation, degeneration and necrosis of the tubular epithelial lining, red blood cell casts, distorted glomerular structure, fibrin thrombi, segmental breaks of the glomerular basal membrane, disruption of Bowman's capsular membrane and crescent formation of the affected glomeruli. An abnormal CXR, an abnormal urinary sediment and a typical kidney histology were used as criteria to diagnose glomerulonefritis with poliangiitis (GPA). Bronchoalveolar lavage smear and PCR turned out positive for mycobacterium tuberculosis. After 3 months of treatment for (GPA) and tuberculosis the patient developed headache and seizure. Cerebral Magnetic Resonance Venography revealed cerebral venous thrombosis of the sinus transverse and sigmoid.

CONCLUSIONS

Tuberculosis may coexist with GPA, as it occurred in our patient. Since a crescentic glomerulonephritis can progress to renal failure, clinicians should always be aware of potential multiple conditions when considering differential diagnoses.

Acute macular neuroretinopathy with coexistent central retinal vein occlusion as the presenting feature in intraocular tuberculosis

Aim

To report a case of intraocular tuberculosis presenting as acute macular neuroretinopathy and central retinal vein occlusion.

Case description

A 29-year-old man presented to the retina clinic with complaints of sudden blurring of vision in the left eye of 3 days duration. His visual acuity was 6/6 and 6/18 in the right and left eye, respectively. Fundus examination of the left eye showed features of central retinal vein occlusion. OCT showed features of type 2 acute macular neuroretinopathy (AMN) as well. Over a period of 2 weeks, the patient developed choroidal granulomas with overlying retinal elevation and peripapillary choroidal neovascular membrane and retinal granuloma. Mantoux test and HRCT chest confirmed the diagnosis of pulmonary tuberculosis.

Results

The patient was treated with a course of antitubercular therapy, oral corticosteroids and a single dose of intravitreal anti-vascular endothelial growth factor (1.25 mg/0.05 ml Bevacizumab, Roche Pharma) injection. After 6 months of therapy with ATT and tapering course of oral steroids, there was a complete resolution of all clinical signs including the choroidal granuloma with an improvement in visual acuity to 6/6.

Conclusion

Acute macular neuroretinopathy can complicate intraocular TB. Tuberculosis should be kept as one of the differential diagnosis in patients with AMN. Prognosis is generally good in patients of ocular TB presenting with retinal vascular occlusions.

Pulmonary vein thrombosis secondary to tuberculosis in a non-HIV infected patient

Our patient is a 67-year-old male with a past medical history significant for hypertension and hyperlipidemia came to a hospital with hemoptysis. He was also having cough and shortness of breath for the last 1 month. He said that his hemoptysis was about 1 cup per day mixed with yellowish sputum. He noticed around 20 pounds of weight loss in the last 1 month. He also complained of night sweats but had no fever. He had no history of travel outside the USA. He has never been incarcerated before, but he endorsed that his son has been to Jail before and he visited him twice a year in patient's home. But he also said that his son has never been diagnosed with TB. He smoked 1.5 packs per day for the last 50 years and quit smoking 2 months ago. His medication include hydrochlorothiazide, lisinopril, gabapentin, aspirin and trazodone. On examination, vital signs were within the normal range except a hearty rate of 106 beats/minute. He had slightly pale conjunctiva, non-icteric sclera and had wet tongue and buccal mucosa. There was decreased air entry with crepitations in the right side of the posterior chest but no wheezes or rales. No peripheral lymphadenopathy, no peripheral edema or sign of fluid collection in the abdomen. Chest x ray showed multiple cavitary lesion in the right upper lobe area. CT scan of the chest with PE protocol showed pulmonary venous partial thrombosis in the right upper lobe. Multiple cavitary lesions with hilar and mediastinal lymphadenopathy. There are also smaller nodular lesions in the left chest too. Small right pleural effusion with multiple calcified granulomata in the left upper lobe. QuantiFERON gold test was found to be positive. Sputum AFB smear was found to be strongly positive and it is sensitive to rifampin. Echocardiography showed no valvular lesions with preserved ejection fraction (>65%) and normal right ventricular size and normal right ventricular systolic pressure. Liver enzymes and renal function tests were found within the normal limit. HIV test was negative. Patient was started with intensive phase anti-tuberculosis treatment with rifampin, isoniazid, ethambutol, pyrazinamide with vitamin B6. He was also started with anticoagulation with heparin and warfarin considering the tuberculosis being the cause of the pulmonary vein thrombosis. Patient was also given supportive treatment and he made a gradual improvement and was discharged with anti-tuberculosis treatment and warfarin. Patient needed to be placed on a higher dose of warfarin as it was difficult to keep him therapeutic with lower doses. He was also advised to follow with infectious disease and anticoagulation clinic. Patient was found to have a significant increase in liver enzymes and bilirubin on follow up and the anti-TB medications were stopped to be restarted one by one with a follow up of his liver enzymes and liver function tests. He was also continued with warfarin.

A rare complication of pulmonary tuberculosis - Pulmonary venous thrombosis with atrial extension

Pulmonary tuberculosis (TB) is serious public health problem in India and worldwide. The mortality rate in pulmonary TB is high in those with advanced disease and in presence of complications. It presents with wide variety of complications of which haematological complications are rare. Many cases were reported pulmonary TB associated with deep venous thrombosis, hepatic and portal venous thrombosis, central retinal venous thrombosis and sagittal sinus thrombosis in TB meningitis. We report a rare case of pulmonary TB with pulmonary venous thrombosis and atrial extension. To our best knowledge, this is the first case reported of its kind.

Anti-VEGF therapy for central retinal vein occlusion caused by tuberculosis-associated uveitis: a case report

BACKGROUND

Tuberculosis (TB)-associated uveitis presents periphlebitis, occasionally causing central retinal vascular occlusion (CRVO). Intravitreal injection of ranibizumab (IVR) is an effective treatment for CRVO, which improves macular edema (ME) by reducing vascular permeability and prevents progression of retinal nonperfusion in CRVO. We report a case of CRVO due to TB-associated uveitis, which initially remitted by repeated IVR as an adjunct to anti-TB therapy and systemic corticosteroids, but subsequently led to severe vitreous hemorrhage (VH).

CASE PRESENTATION

A 28-year-old man was referred to our hospital with a 2-week history of uveitis in his right eye. Ophthalmoscopic examination of the right eye revealed fine keratoprecipitates and moderate cell infiltration into the anterior chamber and vitreous. No obvious retinal lesion was observed. Despite initiation of topical corticosteroids, CRVO developed a few weeks later in the right eye. TB-associated uveitis was diagnosed based on a positive tuberculin skin test and interferon-γ release assay in addition to the ocular findings. Anti-TB therapy together with IVR and systemic corticosteroids was initiated. Although fundus findings associated with CRVO gradually improved, CRVO with VH recurred before the fourth IVR. Although IVR was continued, VH progressed to obscure fundus observation. Therefore, vitrectomy and panretinal photocoagulation were performed. After surgery, ocular inflammation was controlled, and anti-TB therapy was continued for 6 months and was suspended.

CONCLUSION

In addition to anti-TB therapy with or without corticosteroids, panretinal photocoagulation for retinal nonperfusion area in TB-associated uveitis should be performed for preventing neovascularization that may cause VH, and this role of panretinal photocoagulation cannot be replaced by anti-VEGF therapy.

Co-existing tuberculosis and malignant mesothelioma with multiple sites venous thrombosis: a case report

Background

Tuberculosis is endemic in India and almost 40 % of the Indian population is infected with tubercle bacilli. Tuberculosis being a great mimicker of infectious as well as non infectious diseases and recent rise of multi drug resistant and extended drug resistant cases have made diagnosis and management more difficult. To the best of our knowledge there have been no reported cases of tuberculosis coexisting with malignant peritoneal mesothelioma leading to multiple site venous thrombosis.

Case presentation

Forty five year old male, belonging to Indian/Aryan ethnicity presented with cough, breathlessness and fever for 7 months with past history of pulmonary tuberculosis. On examination he was found to have pleural effusion for which he received anti-tuberculosis therapy empirically. Later his condition deteriorated and on further examination he was found to have ascites, multiple site venous thrombosis and pyothorax which was found positive for acid fast bacilli. Despite anti-tuberculosis therapy he did not improve and was suspected to be a multidrug resistant case. Later on computed tomography peritoneal nodule was detected and on biopsy revealed malignant mesothelioma.

Conclusion

In a diagnosed case of tuberculosis with clinical findings compatible with it but not responding to anti tubercular therapy, underlying secondary co-existing pathology should be explored.

Pulmonary Tuberculosis in Humanized Mice Infected with HIV-1

Co-infection with HIV increases the morbidity and mortality associated with tuberculosis due to multiple factors including a poorly understood microbial synergy. We developed a novel small animal model of co-infection in the humanized mouse to investigate how HIV infection disrupts pulmonary containment of Mtb. Following dual infection, HIV-infected cells were localized to sites of Mtb-driven inflammation and mycobacterial replication in the lung. Consistent with disease in human subjects, we observed increased mycobacterial burden, loss of granuloma structure, and increased progression of TB disease, due to HIV co-infection. Importantly, we observed an HIV-dependent pro-inflammatory cytokine signature (IL-1β, IL-6, TNFα, and IL-8), neutrophil accumulation, and greater lung pathology in the Mtb-co-infected lung. These results suggest that in the early stages of acute co-infection in the humanized mouse, infection with HIV exacerbates the pro-inflammatory response to pulmonary Mtb, leading to poorly formed granulomas, more severe lung pathology, and increased mycobacterial burden and dissemination.

Tuberculosis and Acute Deep Vein Thrombosis in a Paediatric Case

Deep vein thrombosis (DVT) may be associated with tuberculosis infection. DVT in tuberculosis (TB) is implicated to the release of inflammatory cytokines, decrease synthesis of anti-coagulant proteins and increased fibrinogen levels. Drugs may also predispose to the hyper-coaguability. DVT may correlate with the severity of mycobacterium infection. We report a case of DVT in an 11-year-old child with sputum positive pulmonary tuberculosis. The patient was put on low molecular weight heparin after Doppler documentation of thrombosis of left femoral vein. She was then put on oral warfarin with complete resolution of the thrombosis. A clinician should be aware of this rare but dangerous association of tuberculosis and must not delay in early diagnosis and intervention.

Ischemic retinal vasculitis and its management

Ischemic retinal vasculitis is an inflammation of retinal blood vessels associated with vascular occlusion and subsequent retinal hypoperfusion. It can cause visual loss secondary to macular ischemia, macular edema, and neovascularization leading to vitreous hemorrhage, fibrovascular proliferation, and tractional retinal detachment. Ischemic retinal vasculitis can be idiopathic or secondary to systemic disease such as in Behçet's disease, sarcoidosis, tuberculosis, multiple sclerosis, and systemic lupus erythematosus. Corticosteroids with or without immunosuppressive medication are the mainstay treatment in retinal vasculitis together with laser photocoagulation of retinal ischemic areas. Intravitreal injections of bevacizumab are used to treat neovascularization secondary to systemic lupus erythematosus but should be timed with retinal laser photocoagulation to prevent further progression of retinal ischemia. Antitumor necrosis factor agents have shown promising results in controlling refractory retinal vasculitis excluding multiple sclerosis. Interferon has been useful to control inflammation and induce neovascular regression in retinal vasculitis secondary to Behçet's disease and multiple sclerosis. The long term effect of these management strategies in preventing the progression of retinal ischemia and preserving vision is not well understood and needs to be further studied.

Unusual presentation of ocular tuberculosis: multiple chorioretinitis, retinal vasculitis and ischaemic central retinal vein occlusion

A 54-year-old male patient presented with a sudden painless visual loss in his left eye. Ophthalmic examinations revealed panuveitis, ischaemic central retinal vein occlusion, multiple chorioretinitis and retinal vasculitis. The diagnosis of tuberculosis was confirmed with anterior tap analysis and QuantiFERON-TB test. Anti-tuberculosis treatment and intravitreal anti-vasculature endothelial growth factor therapy were performed.

Central nervous system tuberculosis presenting as branch retinal vein occlusion

Branch retinal vein occlusion (BRVO) associated with ocular tuberculosis (TB) is a rare presentation of retinal vasculitis but it can also present in the absence of active uveitis. We present a 39-year-old patient with BRVO who slowly developed bilateral papilloedema due to TB in the central nervous system. To our knowledge, this is the first case of systemic central nervous system TB confirmed by biopsy presenting as a branch retinal vein occlusion and shows the importance of extensive causative investigation of BRVO, especially for young patients.

Ocular Tuberculosis Initially Presenting as Central Retinal Vein Occlusion

A 23-year-old man presented with central retinal vein occlusion. The retinal haemorrhages worsened and signs of retinal vasculitis appeared later as vision dropped from 6/60 to Counting Fingers. No signs of systemic disease were observed. Routine Mantoux test and chest radiograph were negative for tuberculosis. Fundus flourescein angiogram confirmed presence of retinal vasculitis. Both systemic and topical corticosteroid therapy were ineffective. Polymerase chain reaction analysis of vitreous fluid showed presence of Mycobacterium tuberculosis. A full 6-month course of antituberculosis therapy was given and inflammation subsided. Vision improved to 3/60. This is a rare case of ocular tuberculosis without evidence of systemic infection, presenting first as a central retinal vein occlusion.