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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 4  |  Page : 686-688

Rare ocular manifestation of papilledema and bilateral choroidal tubercles in disseminated miliary tuberculosis


1 Uveitis Service; Smt Kannuri Santhamma Center for Vitreoretinal Diseases, L V Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, Telangana, India
2 Uveitis Service; Cornea Service, The Cornea Institute, L V Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, Telangana, India
3 Jasti V Ramanamma Children's Eye Care Center, Kallam Anji Reddy Campus, L V Prasad Eye Institute, Hyderabad, Telangana, India

Date of Submission10-Dec-2020
Date of Acceptance16-Mar-2021
Date of Web Publication09-Oct-2021

Correspondence Address:
Dr. Somasheila I Murthy
Department of Cornea, The Cornea Institute, Kallam Anji Reddy Campus, L V Prasad Eye Institute, LV Prasad Marg, Banjara Hills, Hyderabad - 500 034, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_3657_20

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  Abstract 


An 11-year-old female on treatment for miliary tuberculosis presented with decreased vision. Examination revealed bilateral disc edema, granulomatous uveitis, and multiple choroidal tubercles. Oral steroids were added. She was lost to follow-up, and 3 months later she had further visual loss due to optic atrophy. Repeat imaging of the CNS showed regression of the brain parenchymal lesions. This is a rare presentation of ocular tuberculosis in the setting of disseminated TB. While the mainstay of therapy is antitubercular therapy, this case highlights the importance of systemic corticosteroids to decrease both ocular and CNS inflammation and halt further vision loss.

Keywords: Choroidal tubercles, CNS tuberculosis, granulomatous uveitis, miliary tuberculosis, papilledema


How to cite this article:
Reddy S, Murthy SI, Badakere A, Tyagi M, Agarwal H. Rare ocular manifestation of papilledema and bilateral choroidal tubercles in disseminated miliary tuberculosis. Indian J Ophthalmol Case Rep 2021;1:686-8

How to cite this URL:
Reddy S, Murthy SI, Badakere A, Tyagi M, Agarwal H. Rare ocular manifestation of papilledema and bilateral choroidal tubercles in disseminated miliary tuberculosis. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Oct 21];1:686-8. Available from: https://www.ijoreports.in/text.asp?2021/1/4/686/327688



Ocular tuberculosis has a vast spectrum of inflammatory and infectious manifestations.[1] Miliary tuberculosis is known to occur in 20% of extrapulmonary and 2% of pulmonary TB.[2] Massive lympho-hematogenous spread from a primary focus is responsible for the spread.[2] We present a rare case of bilateral granulomatous anterior uveitis with papilloedema and choroidal tubercles in a pediatric patient with miliary tuberculosis.


  Case Report Top


An 11-year-old girl presented with bilateral visual blurring for 15 days. She had been diagnosed with tuberculosis based on weight loss, productive cough, and low-grade fever for 2 months, positive interferon-gamma release assay and sputum examination showing acid-fast bacilli. Contrast-enhanced chest computed tomography showed multiple enlarged lymph nodes with miliary mottling in both lungs. She was on four-drug antitubercular therapy (ATT) for 1 month (isoniazid, rifampicin, pyrazinamide, and ethambutol). The best-corrected visual acuity (BCVA) was 20/20 N6 in the right eye (OD) and 20/25 N12 in the left eye (OS). Slit-lamp examination showed large pigmented keratic precipitates (KP), 2+ cells in the anterior chamber, and 1+ anterior vitreous cells. No relative afferent pupillary defect (RAPD) was noted. Fundus examination [Figure 1]a and [Figure 1]b showed bilateral severe disc edema, tortuous veins, circumferential Paton's lines, peripapillary hemorrhages, and choroidal tubercles. A diagnosis of bilateral papilledema and granulomatous panuveitis was made.
Figure 1: (a and b) Fundus photographs of the right (a) and left eyes, (b) respectively, showing disc edema, dilated, and tortuous retinal veins with peripapillary hemorrhages, circumferential Paton's lines, and choroidal tubercles (yellow arrow) (c and d) OCT of the right (c) and left eyes, (d) respectively, showing choroidal tubercles (yellow arrow) and optic disc edema (red arrow)

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Optical coherence tomography (OCT) through the tubercles [Figure 1]c showed large hyporeflective homogeneous choroidal lesions along with elevation of retinal pigment epithelial and choriocapillaris layer. OCT through the disc [Figure 1]d showed edema. She was referred for urgent magnetic resonance imaging (MRI) brain with gadolinium contrast. Coronal and axial sections [Figure 2]a and [Figure 2]b revealed multiple ring-enhancing lesions scattered in cerebral parenchyma with perilesional edema, suggesting intracranial tuberculomas. She was started on prednisolone acetate 1% and homatropine sulfate 2% eye drops. Tab prednisolone 1 mg/kg body weight was added and ATT was continued. She was referred back to the pediatric neurologist for urgent management of raised intracranial pressure (ICP). Intravenous mannitol was given and the family was counseled and advised hospitalization; however, they decided to take further treatment locally.
Figure 2: (a and b): MRI coronal (a) and axial (b) postcontrast T1-weighted images of the brain showing multiple ring enhancing and solid lesions of varying sizes diffusely scattered in bilateral cerebral hemispheres, thalami, and brainstem suggestive of intracranial tuberculomas

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Three months later, she returned with a severe decrease in vision. On examination, her BCVA was 20/200 and 20/600 in OD and OS, respectively. OS pupil examination showed grade 2 RAPD. Slit-lamp examination showed old pigmented KPs in OS, but no cells in either eye. Fundus evaluation showed persistent papilledema. The choroidal tubercles had resolved. She was referred to the pediatric neurologist and underwent navigation-guided biopsy of the cerebral parenchymal lesions for histopathology, which was reported as features of tuberculosis, whereas microbiology was negative. Repeat MRI showed regression of CNS lesions. ICP was normal. ATT was stepped down to two drugs. Oral prednisolone was increased to 1 mg/kg body weight and tapered and stopped over the next 2 months. Eight months later, BCVA had improved to 20/50, N6 and 20/400, N24 in OD and OS, respectively. Fundus showed optic disc pallor [Figure 3]a and [Figure 3]b. OCT at the final follow-up [Figure 3]c and [Figure 3]d showed no choroidal tubercles. 2-Drug ATT was continued for 1 year. The MRI showed all lesions had resolved.
Figure 3: (a and b): Fundus photographs of the left (a) and right eyes (b), respectively, at last follow-up showing optic atrophy in the left eye (a) and the temporal pallor of the optic disc in the right eye (b) (c and d) OCT at the last follow-up showing no optic disc edema and resolved choroidal hyporeflective tubercles

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  Discussion Top


This case presented with three simultaneously occurring ocular manifestations: Granulomatous panuveitis, bilateral choroidal tubercles, and papilledema, causing decreased vision. After initial therapy, she was lost to follow due to socioeconomic constraints and presented only when her vision had decreased significantly.

The ocular manifestations in tuberculosis have been extensively reported.[3],[4] While choroiditis is the most common intraocular manifestation, the involvement of the optic nerve has also been commonly reported.[1] However, there are few reports of ocular involvement in military tuberculosis. Shiono et al.[5] reported miliary tuberculosis with choroidal hemorrhages, which resolved with ATT. Padhi et al.[6] reported optic disc tuberculoma which responded to oral corticosteroids and ATT. Sengupta et al.[7] reported coexisting military tuberculosis and panuveitis in tubercular meningitis. Mehta evaluated the ocular findings of 11 cases of miliary tuberculosis and concluded that choroidal or retinal tuberculosis in the absence of anterior or intermediate uveitis was the expected pattern.[8] Contrary to the reports mentioned, in our case, papilledema appeared to be the most remarkable feature, followed by the choroidal tubercles. The mechanism of papilledema could be either secondary to raised ICP or secondary to meningeal inflammation. As the raised ICP subsequently normalized after intravenous mannitol and oral steroids, a ventriculoperitoneal shunt was not considered at the initial visit. It is possible that the ICP continued to be elevated for some time, as the patient was lost to follow-up. That would explain the papilloedema going into the chronic stage leading to optic atrophy.

The treatment in addition to ATT also includes systemic corticosteroids as in our case.[9] While the choroidal tubercles appeared to have resolved with no sequelae, the child ended up with subnormal vision due to optic disc atrophy as a consequence of chronic papilledema, which, despite multidisciplinary management with pediatric neurologist and pulmonologist, could not be averted. Another aspect was the use of ethambutol (which is known to cause optic neuropathy) for 2 months, despite disc edema. Ethambutol toxicity is dose dependent, and the incidence is <1% with 15 mg/kg/day of EMB, for more than 2 months.[10]

In view of the CNS lesions, ethambutol was continued and the family was counseled about possible side effects.

At least the systemic disease could be successfully treated and other morbidities could be averted.


  Conclusion Top


To conclude, disseminated tuberculosis can present with varied ocular manifestations due to direct infection, but complications such as papilloedema may occur in CNS involvement.

Acknowledgements

Dr. Lokesh Lingappa, MD, DM, MRCPCH, Consultant Paediatric Neurologist, Rainbow Children's Hospital, Hyderabad, Telangana, India.

Declaration of patient consent

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.

Financial support and sponsorship

Support provided by Hyderabad Eye Research Foundation, Hyderabad, India. The funders had no role in the preparation, review, or approval of the manuscript.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gupta V, Gupta A, Rao NA. Intraocular tuberculosis--An update. Surv Ophthalmol 2007;52:561-87.  Back to cited text no. 1
    
2.
Sharma SK, Mohan A, Sharma A, Mitra DK. Miliary tuberculosis: New insights into an old disease. Lancet Infect Dis 2005;5:415-30.  Back to cited text no. 2
    
3.
Gupta A, Sharma A, Bansal R, Sharma K. Classification of intraocular tuberculosis. Ocul Immunol Inflamm 2015;23:7-13.  Back to cited text no. 3
    
4.
Kaza H, Basu S, Tyagi M, Jakati S, Dave T, Murthy S. Extraocular spread following evisceration for rapidly progressive intraocular tuberculosis. Indian J Ophthalmol 2020;68:2583-5.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Shiono T, Abe SI, Horiuchi T. A case of miliary tuberculosis with disseminated choroidal haemorrhages. Br J Ophthalmol 1990;74:317-9.  Back to cited text no. 5
    
6.
Padhi TR, Basu S, Das T, Samal B. Optic disc tuberculoma in a patient with miliary tuberculosis. Ocul Immunol Inflamm 2011;19:67-8.  Back to cited text no. 6
    
7.
Sengupta S, Tomar V, Biswas J. Coexistent miliary tuberculosis of choroid and tubercular panuveitis: A report. Indian J Ophthalmol 2013;61:761-2.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Mehta S. Patterns of ocular inflammation in patients with miliary tuberculosis. F1000Res 2017;6:412.  Back to cited text no. 8
    
9.
Kadhiravan T, Deepanjali S. Role of corticosteroids in the treatment of tuberculosis: An evidence-based update. Indian J Chest Dis Allied Sci 2010;52:153-8.  Back to cited text no. 9
    
10.
Koul PA. Ocular toxicity with ethambutol therapy: Timely recaution. Lung India 2015;32:1-3.  Back to cited text no. 10
[PUBMED]  [Full text]  


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