Tuberculosis Marco Coassin, Sylvia Marchi, Erika Mandar, Valentina Mastrofilippo, Anna Maria Soldani and Luca Cimino Ocular Immunology Service Ophthalmology Unit: Director Luigi Fontana First Presentation General History
49 year old Caucasian female headache, musculoskeletal pain drowsiness and nausea nurse in an hospital no other risk factors immunocompetent First Presentation - Differential Diagnosis
Viral encephalitis (HSV, VZ, EBV, CMV) Bacterial meningoencephalitis (TB, Syphilis, Brucellosis) Hospitalized in the Dept. of Neurology, started therapy immediately, while waiting for test results First Presentation Lab Tests
chest X-Ray blood tests to rule out systemic infections brain MRI lumbar puncture EEG Mantoux skin test First Diagnosis Viral or bacterial encephalitis Treatment intravenous acyclovir (10 mg/Kg TID) intravenous ceftriaxone (1 gr TID) oral prednisone (25 mg/day) Lab Results Chest X-Ray: negative Blood tests: negative
Mantoux skin test: negative Brain MRI: meningitis with no encephalic lesions EEG: suggestive of meningoencephalitis Lumbar puncture: lymphatic pleiocytosis, PCR negative for viruses STOP of acyclovir From Neuro to Ophtho Eye examination was requested by Neuro only one week after admission, because the patient was complaining of red eyes Ocular Involvement mild conjunctival injection in both eyes
anterior segment was otherwise unremarkable (no cells/flare) BCVA was 20/70 OU IOP 14 OU fundus: bilateral papillitis and whitish chorioretinal lesions STOP corticosteroids First Presentation Ocular Examination First Presentation - Fundus
papillitis disk hemorrages whitish chorioretinal granulomas First Presentation - FLA First Presentation - FLA and ICG
Hyperfluorescence at optic disk head Fluorescence blockage from hemorrages Hypofluorescence from chorioretinal lesions granulomatous posterior Uveitis
New Diagnosis granulomatous posterior Uveitis DD of granulomatous posterior Uveitis
TB Syphilis Vogt-Koyanagi-Harada Sarcoidosis Additional Lab Results
Quantiferon TB-Gold test negative Re-do RPR and TPPA for Lues negative PCR for TB on CSF positive granulomatous posterior Uveitis due to Tuberculosis
Final Diagnosis granulomatous posterior Uveitis due to Tuberculosis Anti-TB Therapy Rifampicine 600 mg/day Isoniazide 300 mg/day
Ethambutol 15 mg/day/Kg Low-dose oral steroids Follow up After 1 Month Follow up After 1 Month Papillitis improved Smaller disk hemorrages
Reduced halo around chorioretinal lesions Final examination After 3 years Final examination After 3 years
Pink optic nerve head Chorioretinal scars/atrophy Final VA 20/20 OU Conclusion Some rare forms of TB infections may assume an
acute presentation and specific test could be negative at first. In the cerebral forms of TB the eyes could be involvedsecondarily Diagnosis from eye samples can be difficult Clinical examination plays a key role in the diagnosis of TB uveitis Consider TB in patients with risk factors (here: nurse)