Transcript Case presentation

Case presentation
By :Saad Aldahmash,MD
History
A 24 years old Saudi young man came to KKESH
E.R on January 2008 ( 3 months) wih Hx of :
*redness on –off OD for 1 year .
*gradual decrease in VA OD over the last 1 year.
*Past ocular Hx was unremarkable.
*Past medical and surgical Hx was
unremarkable.
Family , social History
*His youngest brother died at age of two years
because of chronic cough .
* He is living in Riyadh in a small house
acomodating 12 persons.
He was Examined at that time at KKESH E.R :
*VA … OD 20/70
OS 20/20
*IOP… OD 18 mmHg.
OS 16 mmHg.
*SLE …OD: mutton fat KPs , +3 cells , vitritis .
OS :quiet eye .
B-scan done , showed :only vitreous haze in OD.
He was diagnosed at that time as a case of :
*unilateral Granulomatous panuveitis OD.
*They started to investigate him.
*The patient lost his follow up , didn’t show .
The patient came again to the E.R at
KKESH last week with a Hx :
*Increased Pain ,redness and marked reduction of
VA in OD.
*the patient give a Hx of recent weight loss.
Examination :
VA … OD HM
OS 20/20
IOP… OD 56 mmHg .
OS 18 mmHg .
SLE … OD: corneal edema,scleritis with scleral
melting,mutton fat KPs ,shallow A/C, +4 cells,
360 post. Synechiae , limbal lesion, no view to
post. Pole.
SLE… OS : unremarkable.
B-scan OD : significant vitreous haze .
UBM : showed ciliary body lesion extending
from 3 o’clock to 8 o’oclock position , 360
synaechial angle .
*PPD test ( 5 iu): 10 mm enduration.
*ESR : 67 mm/hr.
*CRP : Positive .
*ACE : normal value.
*HIV, TPHA,RPR : Negative.
*Iron deficiency anaemia .
*CBC: wbc 13.6 Hb 9.7 mg/dl.
*High serum urea and creatinine , low K.
*CT chest: multiple foci of inactive (most likely)TB
granulomas.
•
The Diagnosis :
*Tuberculous panuveitis.
*Ciliary body , limbus, scleral Tuberculous
granuloma .
* Secondary angle closure glaucoma .
Ocular Tuberculosis review
*Actually ,TB can affect any structure of the eye
and adnexia .
*Ocular structures are highly vascularized , high
affinity for TB bacilli.
*Diagnosis of ocular TB is very challenging.
* Most of the times no associated concurrent
active systemic disease.
Review of the litreature
*conjunctival granuloma.
*chronic conjunctivitis.
*Periorbital osteomyelitis.
*orbital granuloma with enophthalmos.
*Orbital Psudotumor like picture.
*Endogenous endophthalmitis.
*panophthalmitis.
*orbital abscess.
*Preseptal cellulitis .
*Retinoblastoma like picture.
*Dacryoadenitit.
*Dacryocystitis.
*NLD obstruction due to nasal
granuloma.
*Primary lid tuberculoma.
*Myositis.
*Phlectenulosis.
*Scleritis.
*keratitis , PUK.
*spontaneous globe perforation.
*Anterior uveitis ( granulomaous , non
granulomatous ).
*Angle , ciliary body granuloma.
*Vitritis.
*papillitis.
*Optic disc tubercle.
*Primary vascular occlusion without
vasculitis.
*vasculitis.
*multifocal
choroiditis,chorioretinitis,retinitis.
*Choroidal tuberculoma without
choroiditis
( similar to metastatic
choroidal lesions).
WHO
*Because of the increase of HIV No of
patients.
*emergence of multidrug resistant strains.
*poor countries where TB is endemic(or
epidemic).
*easy migration between countries .
*late diagnosis (presentation) because of
the masking effect of some antibiotics .
*All previous factors led to an increase
in the TB incidence all over the world.
*TB nowadays, not as before in India
,Africa ,Indonesia…..
It is becoming not uncommon infection
in the US, Europe , also.
TB in KSA
*There were some reports from madina area
of multidrug resistant Mycobacteria
tuberculosis.
*Early diagnosis is very important to
decrease the morbidity, mortality, avoid
high bacterial load of mycobacterium
tuberculosis which make eradication more
difficult.
Conclusion
*TB can mimic many ocular ,adnexal
pathologies.
* TB must be in the differential
diagnosis of any inflammations
,tumors and vascular disorders
affecting the globe and it’s adnexa.
Thank
you