Splenic tuberculosis and multifocal serpiginoid choroiditis.

Serpiginoid multifocal choroiditis is a distinct morphological identity with a reported causal association with Mycobacterium tuberculosis. We report a case of serpiginoid multifocal choroiditis in a 17-year-old boy who was suffering from isolated splenic tuberculosis. He was treated with systemic steroids along with anti-tubercular treatment with good visual recovery. This case was unique as no other organs except spleen and choroid showed tubercular involvement. We hereby emphasize association of extrapulmonary sites with multifocal serpiginoid choroiditis and propose a thorough investigation for primary to be included in routine protocol of choroiditis workup.

[A case of pulmonary tuberculosis associated with orbital myositis].

Ocular tuberculosis is rare. We report a case of orbital myositis suspected to be infected with tuberculosis. In January 2008, a 34-year-old man experienced discomfort in the right eye. In May 2008, this patient developed right exophthalmos, diplopia, and pain in the right eye, and he was diagnosed with idiopathic orbital myositis. The patient underwent 2 courses of steroid pulse therapy; after which, the dosage of steroids was reduced. The steroid treatment reduced the eye pain, but his diplopia and exophthalmos persisted. By November of the same year, his general malaise had increased, and chest X-ray radiography and computed tomography were performed on 3rd December. On the basis of the imaging results, we suspected active pulmonary tuberculosis of the right upper lobe. The smear made by using the sample obtained after bronchial brushing was negative for acid-fast bacilli, but a Mycobacterium tuberculosis nucleic acid amplification test of the post-bronchoscopic sputum yielded positive results. Therefore, the patient was diagnosed with pulmonary tuberculosis. After the 2HREZ/7HR regimen of treatment, the extent of the tuberculosis lesions of the lung was reduced and the exophthalmos and eye pain were alleviated. Orbital myositis is inflammation of the extraocular muscles and can be either idiopathic, without a known etiology, or secondary to conditions such as tuberculosis, sarcoidosis, or hyperthyroidism. Our patient was not definitively diagnosed with tuberculosis of the eye. A definitive diagnosis of tuberculosis of the eye would require detection of granulomatous lesions in the eye or isolation of Mycobacterium tuberculosis by puncturing the eye muscles; however, our findings suggested the possibility that it was secondary to tuberculosis. We think that a careful examination of the chest should be performed for patients with ocular abnormalities.

[Two cases of tuberculous uveitis].

Uveitis has many etiologies, but tuberculous uveitis is rare. We herein report 2 cases of uveitis due to tuberculosis infection. The first case was a 28-year-old man who was showed abnormal shadows in the chest radiographic examination performed in search of the etiology of uveitis. Computed tomography (CT) of the chest revealed hilar and mediastinal lymphadenopathy, small nodules, and consolidation, with a small cavity in the right upper lobe. An ulcerated nodule in the truncus intermedius and stenosis of the right middle lobe bronchus were found on bronchoscopy. The biopsy of the nodule in the truncus intermedius showed a small granuloma containing giant cells, consistent with mycobacterial infection. The culture of bronchial washings from the right upper lobe grew Mycobacterium tuberculosis. Diagnosis of pulmonary tuberculosis, tuberculous lymphadenitis, bronchial tuberculosis, and tuberculous uveitis was made. The patient was treated with antituberculosis drugs and his disease, including uveitis, improved. The second case was a 36-year-old man who presented with right hemiparesis, dysarthria, and visual loss of the left eye. He was diagnosed with neuro-Sweet disease causing optic neuritis and visual loss. His chest CT showed a nodule with centrilobular opacities in the left lower lobe that suggested mycobacterial infection. PCR of the bronchial washing from the left lower lobe was positive for M.tuberculosis and the diagnosis of pulmonary tuberculosis was established. Treatment with antituberculosis drugs and corticosteroids was initiated and his pulmonary lesion improved. However, bilateral tuberculous uveitis developed 15 days after initiation of the treatment. The uveitis gradually deteriorated thereafter despite continuation of antituberculosis therapy. Photocoagulation finally halted the disease progression. In both patients with uveitis presented here, chest radiographs and CT scans were important in determining the etiology of the uveitis. It is difficult to find the etiology of uveitis, and general examinations including the lungs are helpful to pinpoint tuberculosis as the etiology of uveitis. As tuberculous uveitis is sometimes asymptomatic and resistant to treatment, ophthalmological examination is recommended for patients with pulmonary tuberculosis.

Papillitis and neuroretinitis of tuberculous etiology. / Papilitis y neurorretinitis de etiología tuberculosa.

A 57-year-old man with miliary tuberculosis reported visual loss in his right eye, a month after starting a four-drug antituberculous treatment regimen. On exploration, an inferior segmental optic disc edema was objectived and it was attributed to ischemic aetiology. Ethambutol was withdrawn and 60mg of oral prednisone daily were given with a tapering dosage. One and a half months later, he presented a sudden loss of vision in his left eye. In fundoscopy, a papillary edema accompanied by a foveal neurosensory detachment was observed but with no more accompanying uveitic signs. Treatment was intensified with moxifloxacin and corticosteroids were reduced, showing a resolution of the macular detachment but with optic atrophy. Isolated tuberculous involvement of the optic nerve may possible in the context of miliary tuberculosis. In this case, the adopted therapeutic approach to the initial papillitis, which was interpreted as ischemic, could favour the appearance of a neuroretinitis in the fellow eye.

Immune-mediated tuberculous uveitis - A rare association with papulonecrotic tuberculid.

The tuberculids are a group of distinct clinicopathological form of skin lesions representing hypersensitivity reaction to hematogenous dissemination of Mycobacterium tuberculosis or its antigen from an underlying active or a silent focus of tuberculosis elsewhere in the body in an individual with a strong antituberculous cell-mediated immunity and by definition do not show bacilli on special stains and are culture-negative. Ocular involvement can occur in tuberculosis, both due to direct invasion by the bacilli as well as an immune-mediated reaction; however, immune-mediated tuberculous uveitis occurring as a hypersensitivity response in association with PNT has hardly been reported in the literature. Here we report one such rare case.

A CASE OF INTRAVESICAL BACILLUS CALMETTE-GUERIN-RELATED ENDOPHTHALMITIS AND RETINITIS CONFIRMED WITH RETINAL BIOPSY.

PURPOSE: To present a rare case of bilateral endogenous chorioretinitis and unilateral endophthalmitis due to Mycobacterium bovis in a patient who received intravesical bacillus Calmette-Guerin (BCG) treatment. METHODS: We present a case of a single male patient with bilateral endogenous chorioretinitis due to Mycobacterium bovis in a patient who received intravesical BCG, an attenuated strain of M. bovis widely used to treat superficial bladder cancer. The patient underwent intravitreal tap, vitrectomy, and chorioretinal biopsy with histologic examination. RESULTS: The patient presented with a visual acuity of light perception in the right eye and 20/25 in the left eye. Examination of the right eye revealed dense vitreous haze, whereas the left eye demonstrated multifocal, yellow, round subretinal pigment epithelial lesions in the macula. The patient underwent a vitreous tap with injection of antibiotics and was admitted to the hospital for empiric systemic antibacterial and antifungal treatment along with an endogenous endophthalmitis workup. His systemic evaluation and vitreous tap did not identify a causal organism, and the eyes failed to improve on empiric therapies. He underwent pars plana vitrectomy and retinal biopsy of the right eye that revealed vitreal and infiltrative retinal acid-fast bacilli. Cultures confirmed M. bovis to be susceptible to ethambutol, rifampin, and isoniazid. After starting antimycobacterials, his vision improved to finger counting in the right eye, and his vision and appearance of the lesions remained stable in the left eye at postoperative month one. CONCLUSION: Intravesical BCG stimulates a local cell-mediated response that destroys malignant cells. It is generally well tolerated, although it rarely can result in secondary systemic infection. Intravesical BCG-related endophthalmitis is rare and should be considered in the setting of ocular inflammation in patients with a history of bladder cancer who may not disclose previous treatment with BCG.

Presumed localized tuberculous inflammation after periocular procedures.

PURPOSE: To report 4 rare cases of periocular presumed tuberculosis that developed after eyelid and lacrimal drainage surgery. METHODS: Retrospective, interventional case series. Review of clinical, laboratory, photographic, and radiologic records of patients with presumed tuberculous inflammation after periocular procedures. RESULTS: Four patients had periocular presumed tuberculosis after blepharoplasty, dacryocystorhinostomy, and intracanalicular lacrimal plug insertion. Diagnosis was made by characteristic histopathologic findings, acid-fast bacilli staining, polymerase chain reaction results, or response to therapeutic trial. All of the patients underwent antituberculosis chemotherapy for a minimum of 9 months and all recovered. Ectropion and eyelid retraction complicated 2 cases. CONCLUSIONS: Unresponsiveness of chronic inflammation to conventional treatment after periocular procedures should arouse the clinical suspicion of localized tuberculosis, particularly in endemic areas or in patients who have a tuberculosis history or recent exposure. For presumed eyelid tuberculosis without evidence of Mycobacterium tuberculosis, the clinical diagnosis and therapeutic trials could be considered cautiously especially in countries with an intermediate or high tuberculosis burden. Early diagnosis and appropriate treatment can prevent the sequelae of tuberculosis infection.

[Uveitis treated with biotherapy and/or DMARD: Analysis from the French Pharmacovigilance Study Base]. / Uvéites sous biothérapies et/ou DMARDs en rhumatologie : analyse de la base de données déclarative de la pharmacovigilance nationale française.

PURPOSE: To report the characteristics of uveitis cases occurring while on biologic therapy or disease-modifying antirheumatic drugs (DMARDs) reported to the French national pharmacovigilance database. METHODS: All the uveitis cases occurring in patients with chronic rheumatologic diseases, chronic inflammatory intestinal diseases or connective tissue diseases, while treated with DMARDs and/or biologic therapies between 2000 and 2015 and reported to the French National Pharmacovigilance Database were collected. RESULTS: During the study period, 32 cases of uveitis were reported (15 men, 17 women). Two patients were treated with one DMARD alone, 24 with biologic therapy alone, and six with both treatments. Anterior uveitis was diagnosed in 19 patients (8 cases were bilateral); intermediate uveitis was found (unilaterally) in one patient; posterior and diffuse uveitis occurred in 5 and 2 cases respectively. Five cases were inconclusive with regard to the anatomical type of uveitis. The uveitis was of infectious origin in 5 cases: 2 toxoplasmosis, 2 herpes virus and 1 tuberculosis. In the 27 other cases, it was not possible to state whether the uveitis was associated with the underlying disease (uncontrolled) or a side effect of the biologic/DMARD treatments. The occurrence of the uveitis led to 9 switches in biologic therapy and 13 discontinuations of treatment (8 complete discontinuations, 5 discontinuations only until uveitis remission was obtained). In 4 cases, the treatments were not modified. The database does not specify the ultimate course or rheumatologic disease activity at the time of the uveitis. CONCLUSIONS: The presence of uveitis while on biologic therapy must not be taken to indicate a therapeutic failure, especially if the ocular manifestation is isolated. In the case of uveitis occurring in patients treated with biologic therapies and/or DMARDs, infectious complications should be ruled out.

Ophthalmoscopy in the early diagnosis of opportunistic tuberculosis following renal transplant.

Chronic renal failure is a common sequel of renal inflammatory disease or diabetes mellitus. As a result of the immunosuppression that is induced by uremia, hemodialysis or posttransplant immunosuppressive medication, these patients are at a higher risk of opportunistic infections. Various viral, bacterial and mycobacterial infections have been reported. Tuberculosis is a common systemic opportunistic infection but reports of ocular involvement with pulmonary or disseminated tuberculosis are rare. We report the systemic and ocular findings in two postrenal-transplant patients with pulmonary or disseminated tuberculosis in whom detection of choroidal tubercles led to confirmation of the diagnosis in both patients and was the only specific premortem finding in one. Fundoscopy in this group of patients may help in the diagnosis of opportunistic tuberculosis, its earlier treatment and the consequent reduction of morbidity and mortality.

[Ocular manifestation in patients with tuberculosis]. / Alterações oculares em pacientes com tuberculose.

PURPOSE: To analyze clinical findings of ocular tuberculosis and its epidemiological features. METHODS: Were reviewed clinical files of patients who attended the Ophthalmology-Uveitis and AIDS sector of UNIFESP-EPM, São Paulo, Brazil between January 1999 and July 2002 and had a diagnosis of ocular tuberculosis. Patients who had Mantoux test higher than 10 mm, epidemiological history of tuberculosis and ocular findings that improved after specific treatment were included. RESULTS: Seventeen medical files were analyzed, of those, 12 (70.6%) were females. The mean age was 54 (24-84) years. The average time between symptoms and diagnosis was 100 days. Ocular findings at the first interview were multiple but most were at the anterior segment of the eye and 41% of patients who had clinical findings that suggested tuberculosis other than ocular. Situations as glaucoma, retinal detachment and vitreous hemorrhage were responsible for reduction of visual acuity. CONCLUSIONS: Ocular tuberculosis showed a low prevalence but important visual loosing morbidity. The multiplicity of clinical findings is responsible for the delay of diagnosis.

Anterior tuberculous scleritis: A diagnostic challenge.

CASE REPORT: We present the case of a 26 year-old Pakistani male, who after the presumptive diagnosis of anterior tuberculous scleritis (by an atypical clinical appearance and positive epidemiological link), was diagnosed with pulmonary tuberculosis. DISCUSSION: Nodular anterior scleritis is an uncommon presentation of tuberculosis (TB). It is considered a diagnostic challenge because of the difficulty to extract bacilli from the ocular tissue. However, a detailed medical history and eye examination can be the key to an accurate diagnosis and appropriate treatment of the TB.

Presumed ocular and central nervous system tuberculosis in a patient with the acquired immunodeficiency syndrome.

PURPOSE: To elucidate a case of tuberculous choroiditis in a patient with the acquired immunodeficiency syndrome (AIDS). METHODS: We treated a 35-year-old woman who had AIDS with neurologic involvement caused by Mycobacterium tuberculosis. She developed a yellow-white chorioretinal infiltrate with indistinct borders and mild vitreitis in the right eye, probably caused by this pathogen. RESULTS: The patient's visual acuity improved in the right eye with healing of the ocular lesion and her neurologic condition improved after specific therapy with isoniazid, rifampin, and ethambutol. CONCLUSION: Tuberculosis must be considered in the differential diagnosis of posterior uveitis and choroiditis in AIDS patients.

Keratitis.

Corneal inflammation or keratitis is a significant cause of ocular morbidity around the world. Fortunately, the majority of the cases are successfully managed with medical therapy, but the failure of therapy does occur, leading to devastating consequences of either losing the vision or the eye. This review attempts to provide current information on most, though not all, aspects of keratitis. Corneal inflammation may be ulcerative or nonulcerative and may arise because of infectious or noninfectious causes. The nonulcerative corneal inflammation may be confined to the epithelial layer or to the stroma of the cornea or may affect both. For clarity, this section has been divided into nonulcerative superficial keratitis and nonulcerative stromal keratitis. While the former usually includes hypersensitivity responses to microbial toxins and unknown agents, the latter can be either infectious or noninfectious. In the pathogenesis of ulcerative keratitis, microorganisms such as bacteria, fungi, parasites (Acanthamoeba), or viruses play an important role. Approximately, 12.2% of all corneal transplantations are done for active infectious keratitis. Available world literature pertaining to the incidence of microbial keratitis has been provided special place in this review. On the other hand, noninfectious ulcerative keratitis can be related to a variety of systemic or local causes, predominantly of autoimmune origin.

An airman with tuberculous uveitis: case study.

Tuberculosis is endemic, with nearly 2 billion carriers worldwide. Aviation medical examiners should be alert to both its pulmonary and extrapulmonary manifestations, especially in the international traveler. Uveitis is a rare presentation of tuberculosis, but that diagnosis must be considered in the differential, even in the absence of pulmonary disease. Promptly treated, tuberculosis should not interfere with the resumption of a career in aviation, and does not generally require special follow up.

Ocular manifestation of disseminated Mycobacterium simiae infection in a cat.

Disseminated mycobacterial disease was diagnosed in an eight-year-old domestic shorthaired cat, with involvement of the skin, lungs, lymph nodes and one eye. Mycobacterium simiae was cultured from skin biopsies on solid agar and in liquid media. This organism is known to cause pulmonary, cutaneous or disseminated infection in human patients with acquired immunodeficiency syndrome but has never been encountered as a pathogen in companion animals. Combination treatment with rifampicin, enrofloxacin and clarithromycin resulted in complete clinical remission within six months, with no side effects. No recurrence was observed in a 22-month follow-up period.

[Bouchut's tubercles. Clinical and angiographic study, apropos of a case]. / Tubercules de Bouchut. Etude clinique et angiographique, a propos d'un cas.

We report a case of miliary tuberculosis in an 11-year-old child, with phlyctenular keratoconjunctivitis and choroidal tubercles in both fundi. Fluorescein angiography showed early hypofluorescence and late moderate hyperflorescence associated with a disseminated choroidis. The presence of these lesions supported diagnosis of tuberculosis in our patient because of their typical clinical and angiographic aspects.

[Iris tuberculosis. A propos of a case diagnosed by iridectomy]. / Tuberculose irienne. A propos d'une observation diagnostiquée par iridectomie.

Ocular tuberculosis is currently rare in developed countries. We report a case of tuberculous nodular anterior uveitis which revealed primary tuberculosis in a 2-year old girl. This diagnosis was established on microscopic examination of a surgical iridectomy specimen. Thus, a metastatic retinoblastoma was eliminated. The subsequent clinical investigations showed that the girl's father had active pulmonary tuberculosis.

A case of primary lid tuberculosis after upper lid blepharoplasty.

Primary lid tuberculosis after lid surgery is a very rare condition and is likely caused by the introduction of bacilli through epithelial injury. Secondary infection, due to direct hematogenous spread or contiguous spread from adjacent structures are more common presentations of lid tuberculosis. The authors experienced a case of primary lid tuberculosis occurring in a 19 year old female after blepharoplasty for making a eyelid crease. Her upper lid skin showed a reddish and non-tender mass lesion measured 3x1 cm, which was diagnosed as the tuberculosis through typical histopathological findings (caseous necrosis), acid-fast bacilli stain and PCR, and treated with anti-tuberculosis medications.