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AlZaid A, Magliyah MS, AlZahrani Y, ALBalawi HB, AlDhibi H. Uveitic Granulomas Masquerading as Ocular Tumors. Ocul Oncol Pathol 2022; 8:181-186. [PMID: 36938378 PMCID: PMC10015586 DOI: 10.1159/000526817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 08/13/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction Solitary uveal lesions confer a diagnostic challenge to ophthalmologists. Uveitic lesions most abundantly appear amelanotic and commonly involve the choroid. Most amelanotic choroidal lesions are either neoplastic or inflammatory in origin. In our study, we aimed to describe six uveitic granuloma cases, which were referred to a tertiary ophthalmology center as intraocular tumors. Methods Retrospective chart review of 6 patients (7 eyes) who had uveitic granulomas and were referred to a tertiary ophthalmology center as having intraocular tumors. Results Mean age on presentation was 47 ± 12.5 years. One lesion was involving the ciliary body only, five lesions had pure choroidal involvement, and one had ciliochoroidal involvement. Mean visual acuity on presentation was 1.7 ± 0.75 (Snellen = 20/1,000) and ranged from 20/80 to light perception. Mean basal diameter of all lesions was 7.7 ± 1.8 mm. Three lesions had moderate echogenicity, two lesions were low to moderate echoic, and one lesion had moderate to high echogenicity on ultrasonography. Three lesions were associated with retinal detachments. Five eyes showed an early hypofluorescence with late hyperfluorescence. Leakage of fluorescein at borders was noticed in 3 lesions. Final diagnosis was presumed intraocular tuberculosis in 4 patients, probable ocular sarcoidosis in 1 patient, and idiopathic solitary uveitic granulomas in 1 patient. Upon treatment, the vision improved to 0.3 ± 0.27 (Snellen = 20/40) and ranged from 20/20 to 20/100 after 4.7 ± 2.9 years of follow-up. Conclusions Uveitic granulomas can demonstrate features of ocular tumors. Proper uveitis management leads to a favorable visual outcome and ocular preservation.
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Affiliation(s)
- Abdulrahman AlZaid
- Vitreoretinal Division, King Khalid Eye Specialist Hospital, Riyadh, Saudi Arabia
| | | | - Yahya AlZahrani
- Vitreoretinal Division, King Khalid Eye Specialist Hospital, Riyadh, Saudi Arabia
- Ophthalmology Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Hani Basher ALBalawi
- Ophthalmology Division, Department of Surgery, Faculty of Medicine, University of Tabuk, Tabuk, Saudi Arabia
| | - Hassan AlDhibi
- Vitreoretinal Division, King Khalid Eye Specialist Hospital, Riyadh, Saudi Arabia
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2
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Kaur R, Singh H, Khan B, Sehgal A, Aggarwal A. Journey of choroidal tubercle to choroidal granuloma. JOURNAL OF CLINICAL OPHTHALMOLOGY AND RESEARCH 2022. [DOI: 10.4103/jcor.jcor_23_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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3
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Lee DH, Cho H, Lee J, Choi EY, Lee SC, Kim M. Clinical features and long-term treatment outcomes in choroidal tuberculoma. Graefes Arch Clin Exp Ophthalmol 2021; 260:1641-1650. [PMID: 34735633 DOI: 10.1007/s00417-021-05474-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 10/18/2021] [Accepted: 10/20/2021] [Indexed: 10/19/2022] Open
Abstract
PURPOSE To investigate the clinical features and treatment outcomes of patients with choroidal tuberculoma. METHODS In this retrospective, observational case series, the medical records of five patients with choroidal tuberculoma who were followed up at a university hospital for at least 6 months were analyzed. RESULTS Of five patients, one was male and four were female. The overall mean age was 38.0 ± 9.4 years (mean follow-up: 41.2 ± 33.8 months). Tuberculin skin test was performed in three patients, and it was positive in two of them. Interferon-gamma assay was performed in two patients and was positive in all two. Three patients had systemic tuberculosis involving the lung or other organs. Five patients were treated with antitubercular therapy for a period of 9.6 ± 8.6 months. Systemic corticosteroid treatment was performed in 3 patients, with a period of 3.5 ± 0.7 months. One patient with a recurrent vascularized tuberculoma was successfully treated with single intravitreal bevacizumab injection. CONCLUSION Choroidal tuberculoma can develop without evidence of systemic tuberculosis and can recur despite antitubercular treatment. High index of suspicion is important in early detection, and management of choroidal tuberculoma. In cases of suspected choroidal tuberculoma, positive results on immunological tests would be sufficient to initiate antitubercular therapy even if radiological evidence of systemic tuberculosis is not found. Antitubercular therapy combined with systemic corticosteroids provided favorable results. Intravitreal injection of anti-vascular endothelial growth factor may be considered for highly vascularized choroidal tuberculoma.
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Affiliation(s)
- Dong Hyun Lee
- Department of Ophthalmology, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonju-ro, Gangnam-gu, Seoul, Republic of Korea, 06273.,Department of Ophthalmology, Inha University Hospital, Inha University College of Medicine, 27, Inhangro, Jung-gu, Incheon, Republic of Korea
| | - Hyuna Cho
- Department of Ophthalmology, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonju-ro, Gangnam-gu, Seoul, Republic of Korea, 06273
| | - Junwon Lee
- Department of Ophthalmology, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonju-ro, Gangnam-gu, Seoul, Republic of Korea, 06273
| | - Eun Young Choi
- Department of Ophthalmology, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonseiro, Seodaemun-gu, Seoul, Republic of Korea
| | - Sung Chul Lee
- Department of Ophthalmology Konyang University Hospital, Konyang University College of Medicine, 158, Gwanjeodongro, Seo-gu, Daejeon, Republic of Korea
| | - Min Kim
- Department of Ophthalmology, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonju-ro, Gangnam-gu, Seoul, Republic of Korea, 06273.
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Extrapulmonary Tuberculosis—An Update on the Diagnosis, Treatment and Drug Resistance. JOURNAL OF RESPIRATION 2021. [DOI: 10.3390/jor1020015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pathogenic Mycobacterium tuberculosis complex organisms (MTBC) primarily cause pulmonary tuberculosis (PTB); however, MTBC are also capable of causing disease in extrapulmonary (EP) organs, which pose a significant threat to human health worldwide. Extrapulmonary tuberculosis (EPTB) accounts for about 20–30% of all active TB cases and affects mainly children and adults with compromised immune systems. EPTB can occur through hematogenous, lymphatic, or localized bacillary dissemination from a primary source, such as PTB, and affects the brain, eye, mouth, tongue, lymph nodes of neck, spine, bones, muscles, skin, pleura, pericardium, gastrointestinal, peritoneum, and the genitourinary system as primary and/or disseminated disease. EPTB diagnosis involves clinical, radiological, microbiological, histopathological, biochemical/immunological, and molecular methods. However, only culture and molecular techniques are considered confirmatory to differentiate MTBC from any non-tuberculous mycobacteria (NTM) species. While EPTB due to MTBC responds to first-line anti-TB drugs (ATD), drug susceptibility profiling is an essential criterion for addressing drug-resistant EPTB cases (DR-EPTB). Besides antibiotics, adjuvant therapy with corticosteroids has also been used to treat specific EPTB cases. Occasionally, surgical intervention is recommended, mainly when organ damage is debilitating to the patient. Recent epidemiological studies show a striking increase in DR-EPTB cases ranging from 10–15% across various reports. As a neglected disease, significant developments in rapid and accurate diagnosis and better therapeutic interventions are urgently needed to control the emerging EPTB situation globally. In this review, we discuss the recent advances in the clinical diagnosis, treatment, and drug resistance of EPTB.
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Dormegnie LP, Henry A, Salmon JH, N'Guyen Y. No more than meets the eye. Eur J Intern Med 2021; 87:90-91. [PMID: 33814274 DOI: 10.1016/j.ejim.2021.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/17/2021] [Indexed: 11/19/2022]
Affiliation(s)
| | - Adrien Henry
- Service d'Ophtalmologie. Hôpital Robert Debré. Centre Hospitalier Universitaire Reims. France
| | - Jean-Hugues Salmon
- Service de Rhumatologie. Hôpital Maison Blanche. Centre Hospitalier Universitaire Reims. France
| | - Yohan N'Guyen
- Service de Médecine Interne, Maladies Infectieuses et Immunologie Clinique. Hôpital Robert Debré. Centre Hospitalier Universitaire Reims. France.
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Goel N, Kumar V, Arora S, Ghosh B. Massive choroidal granuloma as the presenting feature of disseminated tuberculosis in immunocompetent patients. Clin Exp Optom 2021; 101:607-610. [DOI: 10.1111/cxo.12576] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Neha Goel
- ICARE Eye Hospital and Postgraduate Institute, NOIDA, India,
| | - Vinod Kumar
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India,
| | - Supriya Arora
- Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi, India,
| | - Basudeb Ghosh
- Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi, India,
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Sachan A, Chawla R, Lata S. Large exudative retinal detachment with choroidal granuloma unmasking disseminated tuberculosis: imaging and management. BMJ Case Rep 2021; 14:14/3/e241179. [PMID: 33789862 PMCID: PMC8016067 DOI: 10.1136/bcr-2020-241179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 26-year-old man presented with diminution of vision in the left eye associated with malaise and occasional mild fever. On fundus examination, the patient had left eye inferior bullous retinal detachment with choroidal granuloma. Systemic examination revealed a non-tender swelling on the right wrist. Correlating ophthalmic and systemic findings, a presumptive diagnosis of left eye exudative retinal detachment with choroidal tuberculoma and tubercular osteomyelitis of the right wrist was made. On imaging, asymptomatic multiorgan involvement was observed in the chest, abdomen and spine. The patient was started on antitubercular treatment along with peribulbar steroid. A reduction in size of exudative retinal detachment and tuberculoma with improvement in vision was noted on serial follow-ups. This case highlights the importance of thorough systemic evaluation in cases of ocular tuberculosis as the eye may not be the primary site but the early presenting feature of disseminated tuberculosis. Local posterior subtenon can be used for faster resolution of exudative retinal detachment and intraocular inflammation.
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Affiliation(s)
- Anusha Sachan
- Ophthalmology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Rohan Chawla
- Ophthalmology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Suman Lata
- Ophthalmology, All India Institute of Medical Sciences, New Delhi, Delhi, India
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8
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Lau SL, Iqbal T. Choroidal tuberculoma in the left eye. Assoc Med J 2020. [DOI: 10.1136/bmj.m352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Murthy SI, Rathi VM, Tyagi M, Mishra DK, Pappuru RR. Presumed Intraocular Tuberculosis Manifesting as Unilateral Iris Granuloma. Ocul Immunol Inflamm 2020; 28:1056-1059. [PMID: 31944133 DOI: 10.1080/09273948.2019.1699578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Ocular tuberculosis can manifest in a wide variety of clinical presentations. The prevalence is higher in endemic areas as a cause of granulomatous uveitis. While posterior segment manifestations are well known, anterior segment granulomas alone are relatively rare. We report two cases of unilateral iris granulomata in two young patients who presented with decreased vision and redness and were found to have well-circumscribed iris granulomas. Both underwent systemic evaluation and had a negative Mantoux test. Biopsy pathology of the lesions revealed granulomatous inflammation but were negative for PCR, staining, and culture for TB. One patient turned out to have multiple pulmonary lesions. The ocular condition initially worsened with steroid therapy alone and improved and resolved completely after starting a 9 months course of anti-tubercular therapy (ATT).
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Affiliation(s)
- Somasheila I Murthy
- Cornea Service, Tej Kohli Cornea Institute, Kallam Anji Reddy Campus, L.V. Prasad Eye Institute , Hyderabad, India
| | - Varsha M Rathi
- Allen Foster Research Centre for Community Eye Health, Gullapalli Pratibha Rao International Centre for Advancement of Rural Eye Care, L V Prasad Eye Institute , Hyderabad, India
| | - Mudit Tyagi
- Smt Kannuri Santhamma Vitreoretinal Services, KallamAnji Reddy Campus, L.V. Prasad Eye Institute , Hyderabad, India
| | - Dilip Kumar Mishra
- Ophthalmic Pathology Service, Hyderabad Eye Research Foundation, L.V. Prasad Eye Institute , Hyderabad, India
| | - Rajeev R Pappuru
- Smt Kannuri Santhamma Vitreoretinal Services, KallamAnji Reddy Campus, L.V. Prasad Eye Institute , Hyderabad, India
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Boubnan Y, Lezrek O, Laghmari M, Cherkaoui O. Choroidal granuloma secondary to tuberculosis in an immunocompromised patient. J Fr Ophtalmol 2019; 42:e245-e246. [DOI: 10.1016/j.jfo.2018.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 11/03/2018] [Accepted: 11/14/2018] [Indexed: 11/27/2022]
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Asensio-Sánchez VM, Díaz-Cabanas L, Martín-Prieto A, Haro-Álvarez B. Asymptomatic choroidal tubercle in a patient with Crohn's disease on adalimumab treatment. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2018; 93:147-150. [PMID: 28743416 DOI: 10.1016/j.oftal.2017.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 05/27/2017] [Accepted: 06/21/2017] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Adalimumab, an anti-tumour necrosis factor alpha therapy for active Crohn's disease (CD), is associated with increased risks of tuberculosis infection. CASE REPORT The case is presented of a 48 year-old male with active CD on treatment with adalimumab. After three months, he developed a miliary pulmonary tuberculosis infection, with a solitary non-reactive choroidal tubercle temporal-superior to the optic disc being found in an ophthalmological study. Fluorescein angiography showed late hyperfluorescence in a staining pattern. Optic coherence tomography showed a flat mass without serous retinal detachment. The choroidal tubercle slowly regressed with antituberculosis therapy. DISCUSSION Choroidal tubercles with no vitreo-retinal symptomatology can be present in patients with CD and on treatment with adalimumab.
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Affiliation(s)
- V M Asensio-Sánchez
- Servicio de Oftalmología, Hospital Clínico Universitario, Valladolid, España.
| | - L Díaz-Cabanas
- Servicio de Oftalmología, Hospital Clínico Universitario, Valladolid, España
| | - A Martín-Prieto
- Servicio de Oftalmología, Hospital Clínico Universitario, Valladolid, España
| | - B Haro-Álvarez
- Servicio de Oftalmología, Hospital Clínico Universitario, Valladolid, España
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Kumar P, Kakkar P, Ravani R, Karthikeya R, Kumar A. Splenic tuberculosis and multifocal serpiginoid choroiditis. Int Ophthalmol 2017; 38:2191-2194. [PMID: 28798995 DOI: 10.1007/s10792-017-0689-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 08/07/2017] [Indexed: 10/19/2022]
Abstract
Serpiginoid multifocal choroiditis is a distinct morphological identity with a reported causal association with Mycobacterium tuberculosis. We report a case of serpiginoid multifocal choroiditis in a 17-year-old boy who was suffering from isolated splenic tuberculosis. He was treated with systemic steroids along with anti-tubercular treatment with good visual recovery. This case was unique as no other organs except spleen and choroid showed tubercular involvement. We hereby emphasize association of extrapulmonary sites with multifocal serpiginoid choroiditis and propose a thorough investigation for primary to be included in routine protocol of choroiditis workup.
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Affiliation(s)
- Pradeep Kumar
- Unit 2, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
| | - Prateek Kakkar
- Unit 2, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Raghav Ravani
- Unit 2, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - R Karthikeya
- Unit 2, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Atul Kumar
- Unit 2, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
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Abstract
Infectious uveitis accounts for majority of the cases of uveitis in developing countries. It also encompasses an array of various microorganisms and their clinical presentations. Some of these infectious uveitic entities are familiar, while others are newly emerging in the global ophthalmic world. Many of these entities are also a major cause of morbidity and mortality, and appropriate, timely management is required to save not the eye, but life of the patient. This review highlights the ocular manifestations of various infectious uveitic entities, relevant to the ophthalmologist.
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Affiliation(s)
| | - Avirupa Ghosh
- Department of Uvea, Aditya Birla Sankara Nethralaya, Kolkata, India
| | - Jyotirmay Biswas
- Department of Uvea, Sankara Nethralaya, Chennai, Tamil Nadu, India
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Paez Soria E, Magnano P, Schlaen A, Luvini P, Arevalo Calderon G, Martinez Cartier M, Chiaradía P, Couto C. Tuberculous Subretinal Abscess in a Non-HIV Patient with Miliary Tuberculosis. Case Rep Ophthalmol 2016; 7:292-300. [PMID: 28101049 PMCID: PMC5216240 DOI: 10.1159/000453447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 11/15/2016] [Indexed: 11/19/2022] Open
Abstract
This case report describes the features of a tuberculous subretinal abscess in a non-HIV patient. It includes the characterization of the lesion with spectral-domain optical coherence tomography (SD-OCT) and fundus autofluorescence examination. SD-OCT and autofluorescence imaging showed external retinal involvement during development of the tuberculous subretinal abscess. Patients with tuberculous lesions need a multidisciplinary approach, since the disease may involve any part of the body. In this case in particular, incidental findings at computed tomography scan led to the detection of this rare ocular manifestation of tuberculous disease.
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Affiliation(s)
- Eugenia Paez Soria
- Department of Ophthalmology, University of Buenos Aires, Buenos Aires, Argentina
| | - Paula Magnano
- Department of Ophthalmology, University of Buenos Aires, Buenos Aires, Argentina
| | - Ariel Schlaen
- Department of Ophthalmology, University of Buenos Aires, Buenos Aires, Argentina
- *Dr. Ariel Schlaen, Department of Ophthalmology, University of Buenos Aires, Arenales 981 2do Piso, Buenos Aires C1061AAE (Argentina), E-Mail
| | - Paula Luvini
- Department of Internal Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | | | | | - Pablo Chiaradía
- Department of Ophthalmology, University of Buenos Aires, Buenos Aires, Argentina
| | - Cristóbal Couto
- Department of Ophthalmology, University of Buenos Aires, Buenos Aires, Argentina
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Kumar N, Sudharshan S, Ganesh SK, Lingam G, Biswas J. Bilateral multiple choroidal granulomas and systemic vasculitis as presenting features of tuberculosis in an immunocompetent patient. J Ophthalmic Inflamm Infect 2016; 6:40. [PMID: 27785746 PMCID: PMC5081311 DOI: 10.1186/s12348-016-0109-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 10/08/2016] [Indexed: 11/21/2022] Open
Abstract
Background Multiple choroidal granulomas are a rare presentation of tuberculosis. Choroidal granulomas in immunocompetent patients can pose difficulty in diagnosis as in most cases systemic examination may not reveal any evidence of tuberculosis. We report a case of bilateral multiple choroidal granulomas with systemic vasculitis-like features and disseminated tuberculosis in an immunocompetent patient without pulmonary involvement. Findings A 26-year-old male Indian patient presented with bilateral blurred vision and systemic illness with vasculitis-like features. Examination revealed bilateral multiple choroidal granulomas and multisystem involvement without pulmonary involvement. Aqueous tap was positive for mycobacterium by polymerase chain reaction along with tissue biopsy leading to diagnosis. There was a good systemic and ocular response to anti-tubercular therapy with resolution of lesions. Conclusions Our case emphasizes that, although uncommon, tuberculosis can involve multiple organs without pulmonary involvement and may mimic systemic vasculitis, it is not mandatory to have pulmonary findings for a confirmation of tuberculosis. Timely diagnosis with appropriate treatment can improve systemic and ocular disease.
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Affiliation(s)
- Nitin Kumar
- Medical and Vision Research Foundations, Sankara Nethralaya, 18, College Road, Chennai, 600006, India
| | - Sridharan Sudharshan
- Medical and Vision Research Foundations, Sankara Nethralaya, 18, College Road, Chennai, 600006, India.
| | - Sudha K Ganesh
- Medical and Vision Research Foundations, Sankara Nethralaya, 18, College Road, Chennai, 600006, India
| | - Gopal Lingam
- Medical and Vision Research Foundations, Sankara Nethralaya, 18, College Road, Chennai, 600006, India
| | - Jyotirmay Biswas
- Medical and Vision Research Foundations, Sankara Nethralaya, 18, College Road, Chennai, 600006, India
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