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Tuberculosis
Marco Coassin, Sylvia Marchi,
Erika Mandarà, 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
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
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 involved
secondarily
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)