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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 3  |  Page : 700-703

Refractory bilateral choroiditis due to presumed ocular tuberculosis responding to intravitreal moxifloxacin


Department of Ophthalmology, Vittala International Institute of Ophthalmology & Prabha Eye Clinic and Research Center, Bangalore, Karnataka, India

Date of Submission06-Dec-2021
Date of Acceptance07-Mar-2022
Date of Web Publication16-Jul-2022

Correspondence Address:
Dr. Kalpana Babu
Prabha Eye Clinic & Research Centre, 504, 40th Cross, Jayanagar 8th block, Bangalore - 560 070, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_3052_21

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  Abstract 


A rare presentation of bilateral refractory choroiditis due to presumed ocular tuberculosis with dramatic response to intravitreal moxifloxacin is described in this report. A 32-year-old lady with a past history of bilateral choroiditis due to presumed ocular tuberculosis and biopsy-proven tubercular lymphadenitis four years ago came to us with reactivation of inflammation refractory to antitubercular therapy, systemic steroids, vitrectomy and intravitreal anti-VEGF injections. The lesions responded dramatically to intravitreal injections of moxifloxacin and dexamethasone. Following this dramatic response, she also received oral moxifloxacin 800 mg/day along with ATT for a year. At two-year follow-up, she is doing well with no further recurrences. To the best of our knowledge, no cases of tubercular choroiditis responding to moxifloxacin have been reported (MEDLINE search). This case highlights the usefulness of intravitreal moxifloxacin in refractory tubercular choroiditis.

Keywords: Bilateral, choroiditis, moxifloxacin, refractory, tuberculosis


How to cite this article:
Babu K, Shah D, Murthy KR. Refractory bilateral choroiditis due to presumed ocular tuberculosis responding to intravitreal moxifloxacin. Indian J Ophthalmol Case Rep 2022;2:700-3

How to cite this URL:
Babu K, Shah D, Murthy KR. Refractory bilateral choroiditis due to presumed ocular tuberculosis responding to intravitreal moxifloxacin. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 13];2:700-3. Available from: https://www.ijoreports.in/text.asp?2022/2/3/700/351168



We report an interesting course of bilateral refractory choroiditis due to presumed ocular tuberculosis with dramatic response to intravitreal moxifloxacin and dexamethasone.


  Case Report Top


A 32-year-old lady was referred to our hospital in November 2019 with history of diminution of vision, redness, persistent pain, and inability to open her eyes of five months duration. She was on a second course of a four-drug regimen of antitubercular therapy (isoniazid + rifampicin + pyrazinamide + ethambutol) and oral steroids (40 mg/day) since four months for a recurrence of bilateral choroiditis with no improvement in symptoms. Old records showed a history of biopsy-proven tubercular cervical lymphadenitis and bilateral choroiditis 4 years ago, for which she had received 4 doses of intravenous methyl prednisolone, followed by oral steroids for ocular inflammation and a 12-month course of a 4-drug regimen of antitubercular therapy by her treating physician.

On examination, her BCVA was 6/9 (OD) and counting fingers close to face (OS). Slit-lamp and fundus examinations showed an AC reaction 1+, vitritis 1+(SUN[1]), active choroiditis around area of pigmented chorioretinal scar temporal to the fovea (OD) and around the disc and posterior pole (OS). Autofluorescence imaging showed fuzzy hyperfluorescence at the edges of the choroiditis, central areas of stippled hyperfluorescence and hypofluorescence. fundus fluorescein angiography (FFA) showed areas of initial hypofluorescence in early phases and leakage in mid and late phases. Retinal vascular leakage was also noted in late phases (OS > OD). ICG shows hypocyanescence. Enhanced Depth Imaging Optical Coherence Tomography (EDI-OCT) showed choroidal elevation with double layer sign[2] and intraretinal fluid cystic spaces. B-scan showed localized choroidal thickening (3.74 mm in OD and 4.20 mm in OS) with underlying sub-tenon's space widening, suggestive of associated posterior scleritis [Figure 1]. Laboratory investigations showed normal complete hemogram, liver and renal functions, blood sugars, urine routine and immunoglobulin profile. QuantiFERON TB gold, VDRL, TPHA, ELISA for toxoplasmosis (IgG & IgM) and HIV were negative. Imaging including high-resolution CT (HRCT) thorax, MRI orbits and cranium, ultrasonography of neck and abdomen did not reveal any abnormality. Serum angiotensin converting enzyme, CD4 and CD8 were normal. There was worsening of the choroiditis (OD) with severe pain and ILM folds over the macula and a drop in vision to 6/18 in next four days [Figure 1]. As all investigations were negative, a vitreous biopsy with vitrectomy and intravitreal anti-VEGF injection was given in the left eye. Post vitrectomy, symptoms improved slightly in the left eye. Subsequently right eye was also given intravitreal injection of anti-VEGF (ranibizumab 0.5 mg/0.05 ml). However, her symptoms of pain and diminution of vision worsened post anti-VEGF in OD with worsening of choroiditis and occurrence of a sub macular hypopyon [Figure 2]. As the T sign worsened, she was given pulse doses of intravenous methyl prednisolone 1 gm/day over 3 days. Though the pain reduced, lesions were persistent, active and vision threatening (OD). PCR on the vitreous biopsy were negative for eubacterial, pan fungal genomes and positive for IS6110 gene and negative for MPB64 gene of Mycobacterium tuberculosis. Real-time PCR (MTb) showed 3,244 copies/ml. Heat shock protein was negative for non-mycobacterial MTb. AFB staining, Gene Xpert Gene Ultra and Rpb0 sequencing were negative. Bacterial and fungal cultures were negative. Cytology showed numerous macrophages and lymphocytes consistent with chronic inflammatory pathology. As lesions were still active with occurrence of new lesions, she received intravitreal injections of moxifloxacin (200 μg/0.05 ml) and dexamethasone (200 μg/0.05 ml) three days post IVMP in the right eye, and two days later in the left eye. A drastic improvement in inflammation in both eyes were noted [Figure 3]. Due to the dramatic response with intravitreal moxifloxacin, she was also started on systemic moxifloxacin 800 mg along with anti-TB treatment (ATT) by the infectious disease specialist and the oral steroids were tapered slowly. She received three injections of moxifloxacin and dexamethasone over three weeks at weekly intervals (OU). At three weeks, EDI-OCT and B-scan showed decreased choroidal thickening (OD: 1.47 mm; OS: 1.36 mm). Mycobacterial growth indicator tube (MGIT) culture for mycobacterial and non-mycobacterial tuberculosis at the end of 42 days were negative. After two months, she developed a slight pain and a new active lesion in the left eye. Two intravitreal injections of moxifloxacin and dexamethasone at weekly intervals was given till resolution of lesion. When she came for a review after five months (due to the corona pandemic), the lesions had resolved very well [Figure 3]. At two-year follow-up, both eyes were quiet with no recurrences. Her BCVA was 6/6 (OD) and counting fingers close to face (OS).
Figure 1: Composite photographs of the right eye showing active inflammation with hemorrhages around pigmented chorioretinal scar temporal to fovea (a); fuzzy hyperfluorescence on autofluorescence (b); EDI-OCT showing choroidal elevation at the active edge and double layer sign (c); FFA & ICG in mid phases showing hypofluorescence in midphases and hyperfluorescence suggestive of choroiditis in late phases with areas of retinal vascular leakage (d and e); Ultrasonography showing choroidal thickening and dome-shaped elevation corresponding to the area of activity (f); Composite photographs of left eye showing hazy media with active inflammation (g) with hypofluorescence around the optic disc with fuzzy hyperfluorescence on autofluorescence (h); EDI-OCT showing extensive choroidal elevation at the active edge and overlying intraretinal edema (i); FFA & ICG in mid phases showing hypofluorescence in mid phases and hyperfluorescence suggestive of choroiditis in late phases with extensive areas of retinal vascular leakage (j and k); ultrasonography showing choroidal thickening and dome-shaped elevation corresponding to the area of activity (l)

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Figure 2: Composite photograph of right eye showing worsening of inflammation (a); with fuzzy hyperfluorescence on autofluorescence (OD) following anti-VEGF injection (b); EDI-OCT (OD) showing increased choroidal thickening with subretinal fluid (c); Composite photograph of left eye showing improved media clarity post vitrectomy and anti-VEGF injection (d); fuzzy hyperfluorescence on autofluorescence (e); EDI-OCT following vitrectomy showing choroidal elevation and thickening with subretinal fluid (f); Ultrasonography showing choroidal thickening with dome shaped elevation with fluid in sub-tenon's space in right (g) and left (h) eyes; Microphotograph showing lymphocytes and macrophages suggestive of chronic granulomatous inflammation (i) and real-time PCR positivity for MTb (j)

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Figure 3: Composite photograph showing autofluorescence and EDI-OCT photographs showing dramatic improvement with intravitreal moxifloxacin and dexamethasone injections in right (a, c, e) and left (b, d) eyes, fuzzy hyperfluorescence and choroidal elevation (yellow arrow) at the end of two-months in the left eye indicating an active lesion (f), healed lesions at the end of six months showing hypofluorescence on autofluorescence and EDI-OCT showing hyperreflective, knob-like elevations of RPE-Bruch's complex suggestive of scarring in right (g) and left (h) eyes

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  Discussion Top


We report an interesting and atypical case of bilateral refractory choroiditis due to presumed ocular tuberculosis responding to intravitreal moxifloxacin. This case is interesting due to many reasons. Firstly, the patient had a history of bilateral tubercular choroiditis and biopsy-proven tubercular cervical lymphadenitis four years ago which was completely treated with antitubercular therapy and systemic steroids. The reactivation of ocular inflammation after four years with no systemic reactivation and its refractory course to oral steroids and second course of antitubercular therapy was puzzling. Secondly, vitrectomy with anti-VEGF injection in the left eye seemed to have temporarily improved the inflammation. It has been known that tubercular granulomas express increased VEGF and hence, anti-VEGF injections may be useful in resolution of tubercular lesions, especially granulomas.[3],[4],[5] However, contrary to the response in the left eye, anti-VEGF injection worsened the inflammation in the right eye. Thirdly, the real-time PCR from the vitreous sample was positive for IS6110 gene and negative for MPB64 gene of Mycobacterium tuberculosis. Gene Xpert and Gene Ultra tests were negative. Hence, is difficult to ascertain if it is drug-resistant TB. Atypical and non-mycobacterial infections were also ruled out. Moxifloxacin is a second-line drug usually used in drug-resistant tuberculosis. The response to intravitreal moxifloxacin in our case was dramatic which prompted the infectious disease specialist to start systemic moxifloxacin even in the absence of positive culture.


  Conclusion Top


To date, there are no reports of refractory tubercular choroiditis treated with intravitreal moxifloxacin to the best of our knowledge. Although this is a single case report, we believe that this it highlights the challenges in management of tubercular choroiditis in TB endemic countries and brings to light an important drug like moxifloxacin in our treatment armamentarium for such refractory cases.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jabs DA, Nussenblatt RB, Rosenbaum JT; Standardization of Uveitis Nomenclature (SUN) Working Group. Standardization of uveitis nomenclature for reporting clinical data. Results of the First International Workshop. Am J Ophthalmol 2005;140:509-16.  Back to cited text no. 1
    
2.
Konana VK, Bhagya M, Babu K. Double layer sign: A new OCT finding in active tubercular serpiginous like choroiditis to monitor activity. Ophthalmology Retina 2020;4:336-42.  Back to cited text no. 2
    
3.
Kee AR, Gonzalez-Lopez JJ, Al-Hity A, Gupta B, Lee CS, Gunasekeran DV, et al. Anti-tubercular therapy for intraocular tuberculosis: A systematic review and meta-analysis. Surv Ophthalmol 2016;61:628-53.  Back to cited text no. 3
    
4.
Babu K, Murthy PR, Murthy KR. Intravitreal bevacizumab as an adjunct in a patient with presumed vascularized choroidal tubercular granuloma. Eye (Lond) 2010;24:397-9.  Back to cited text no. 4
    
5.
Agarwal M, Gupta C, Mohan KV, Upadhyay PK, Dhawan A, Jha V. Adjunctive intravitreal anti-vascular endothelial growth factor and moxifloxacin therapy in management of intraocular tubercular granulomas. Ocul Immunol Inflamm 2021;17:1-10.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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