Primary Orbital Tuberculosis with Cold Abscess: A Case Report.

Orbital tuberculosis is a rare form of extrapulmonary tuberculosis involving orbital soft tissue, periosteum, bones and lacrimal glands. This is a case report of a 6-year-old male child who presented with swelling of the right upper eyelid. He had normal visual acuity without signs of diplopia or ophthalmoplegia. The tuberculin skin test was reactive and the computed tomography scan showed peripherally enhancing collection with bony erosion and intracranial extension in the extraconal space of the superolateral right orbit. Orbital exploration was done which showed caseous material. The histological examination revealed necrotizing granulomatous tissue. The caseous material on Ziehl Neelsen staining confirmed acid-fast bacilli causing a tubercular abscess. The child is currently on anti-tubercular therapy planned for 12 months. Orbital tuberculosis might or might not be in association with pulmonary tuberculosis and should always be taken into consideration while dealing with chronic inflammatory orbital disease and an orbital mass. Keywords: case reports; orbit; tuberculosis.

Ocular tuberculosis presenting with a conjunctival granuloma.

An 18-year-old female patient was referred with complaints of tearing and redness in the left eye for 3 months after a mild ocular trauma with a turkey feather. She was treated with topical antibiotics and corticosteroids with no improvement. Slit-lamp examination of the left eye showed a vascularized lesion with a polypoidal appearance due to multiple contiguous micronodules on the temporal and inferior bulbar conjunctiva. Results of the anterior and posterior segment examination were unremarkable in both eyes. A biopsy specimen of the conjunctival mass showed multiple tuberculoid granulomas composed of epithelioid histiocytes with associated Langhan's type multinucleate giant cells and a necrotic nodule surrounded by histiocytes and giant cells. The Mantoux test was positive with induration of 15mm. The patient was prescribed antituberculosis therapy. Three months after treatment initiation, the conjunctival lesions had resolved. Mycobacterium tuberculosis should be considered in cases of unilateral chronic recalcitrant conjunctivitis. Biopsy of a conjunctival mass is of utmost importance to establish a definite diagnosis.

Presumed tuberculosis-related scleritis.

AIMS: To evaluate the clinical characteristics and therapeutic outcome of patients with recurrent scleritis of unknown demonstrable aetiology and positive QuantiFERON-TB Gold In-Tube test (QFT). METHODS: Retrospective chart review of the demographic, clinical, laboratory and therapeutic outcome data of 15 patients. Clinical characteristics as well as remission rate after standard antituberculous therapy (ATT) were assessed. RESULTS: There were 9 men and 6 women with a mean age of 48.9 years (range, 32-73). Scleritis was diffuse in 10 patients (66.6%) and nodular in 5 patients (33.3%), 1 of them with concomitant posterior scleritis. It was bilateral in 7 patients (46.6%) and recurrent in all of them. Scleritis appeared after prior uveitis (10 patients, 66.6%) and/or with concomitant uveitis (5 patients, 33.3%) or peripheral keratitis (5 patients, 33.3%). Previous ocular surgery was found in 7 patients (46.6%). Previous extraocular tuberculosis (TB) infection or previous TB contact was detected in 11 patients (73.3%). No radiologic findings of active extraocular TB were detected. ATT was used in 15 patients, sometimes with the addition of systemic corticosteroids (5 patients) and methotrexate (1 patient); 14 patients achieved complete remission (93.3%). CONCLUSION: Presumed TB-related scleritis may appear in recurrent scleritis of unknown origin and positive QFT. It may occur after prior uveitis and/or concomitantly with uveitis or peripheral keratitis, and it may be triggered by previous ocular surgery. No patients had evidence of concurrent active extraocular infection, although many had previous TB infection or TB contact. ATT was effective, sometimes with the addition of systemic corticosteroids and methotrexate.

Role of Interferon-Gamma Release Assay for the Diagnosis and Clinical Follow up in Ocular Tuberculosis.

PURPOSE: To assess the performance of interferon-gamma release assay (IGRA) associated with tuberculosis skin test (TST) for ocular tuberculosis (OTB) diagnosis and therapeutic decision making. METHOD: One hundred and ninety-one patients with ocular inflammation were prospectively followed-up. Patients with clinical signs highly suspected of OTB, TST≥10 mm, and/or IGRA≥0.35 IU/mL received antitubercular therapy (ATT). Sensitivity (Se), specificity (Sp), and area under the curve (AUC) were assessed. RESULTS: Seventy-two (37.7%) patients received ATT for presumed OTB. Combining TST and IGRA had Se=89.6%, Sp=99.2%, and AUC (0.98) significantly higher compared to TST (0.85, Z=6.3, p<.001) or IGRA (0.95, Z=2.5, p=.01). Prior history of corticosteroids or immunosuppressant with concomitantly oral prednisone and baseline IGRA> 2.0 IU/mL was associated significantly with more recurrences in ATT patients (p=.01)      . CONCLUSION: Considering TST and IGRA together was more effective in assessing OTB diagnosis. The real value of the IGRA test to predict recurrences needs further studies.

Multifocal choroiditis and choroidal tuberculoma: Signs of presumed ocular tuberculosis.

The diagnosis of OTB (Ocular tuberculosis) is usually difficult to make. Definitive diagnosis requires the identification of M. tuberculosis organisms in ocular tissues or fluids, but samples are often difficult to obtain, and biopsy may be hard to justify. We describe a 50-years-old Maghreb male, who presented a multifocal choroiditis associated with a choroidal tuberculoma on the left eye. Based on positive QuantiFERON-TB-Gold test and suggestive clinical and radiographic findings, a diagnosis of presumed ocular tuberculosis was made. Serial swept-source optical coherence tomography (SS-OCT) and widefield fundus retinographies during subsequent follow-up visits demonstrated the characterization of the atypical tuberculosis presentation and allowed the assessment of response to antitubercular therapy and oral steroids.

Anti-tubercular therapy in the treatment of tubercular uveitis: A systematic review and meta-analysis.

We quantitatively evaluated the efficacy of antitubercular therapy (ATT) in tubercular uveitis (TBU) patients. Main outcome measures include inflammation recurrence, inflammation reduction, complete resolution of inflammation, improved visual acuity (VA), ability to taper corticosteroids to < 10 mg/day without inflammatory progression, and use of adjunctive immunosuppressants while on ATT. This review is prospectively registered in PROSPERO (CRD42020206845). Forty-nine studies reporting data for 4,017 TBU patients were included. In comparative studies, the odds ratio (OR) of inflammatory recurrence was 0.33 (95%CI:0.19-0.60) for TBU patients treated with ATT±corticosteroid versus no ATT. For TBU patients treated with ATT±corticosteroid, the pooled absolute incidences of inflammatory recurrence, inflammatory reduction, complete resolution of inflammation, and visual acuity improvement were 13% (n=310/2,216; 95%CI:9-18), 81% (n=217/276; 95%CI: 62-95), 83% (n=1,167/1,812; 95%CI: 77-89), and 65% (n=347/542; 95%CI:51-78), respectively. Corticosteroids were tapered to <10 mg/day without inflammatory progression in 91% (n=326/395; 95%CI:78-99) of patients, 9% (n=121/1,376; 95%CI:6-13) of whom were administered concomitant immunosuppressive agents alongside ATT. We conclude that treatment of TBU with ATT±corticosteroid is associated with a high level of control or improvement of inflammation. More prospective studies with detailed reporting of ATT regimens, patient subgroups, and outcomes are required to better evaluate ATT effectiveness.

Could different aqueous humor and plasma cytokine profiles help differentiate between ocular sarcoidosis and ocular tuberculosis?

OBJECTIVE AND DESIGN: A cross-sectional single-center study was conducted to assess cytokine levels in aqueous humor (AH) and plasma of three different uveitis entities: definite ocular sarcoidosis (OS), definite OS associated with QuantiFERON®-TB Gold test positivity (Q + OS) and presumed tubercular uveitis (TBU). SUBJECTS: Thirty-two patients (15 OS, 5 Q + OS, 12 TBU) were included. METHODS: Quantification of selected cytokines was performed on blood and AH samples collected before starting any treatment. Statistical analysis was conducted using the Kruskal-Wallis test, the Mann-Whitney or Fisher test and the Principal Component Analysis (PCA). RESULTS: IL-6, IL-8 and IP-10 levels were higher in AH samples than in peripheral blood. In AH samples, BLC, IL-8 and IP-10 were significantly higher in definite OS than in presumptive TBU. There were no statistically significant differences in terms of cytokine levels between Q + OS and presumptive TBU. PCA showed a similar cytokine pattern in the latter two groups (IFNγ, IL-15, IL-2, IP-10, MIG), while the prevalent expression of BLC, IL-10 and MIP-3 α was seen in definite OS. CONCLUSIONS: The different AH and plasma cytokine profiles observed in OS compared to Q + OS and TBU may help to differentiate OS from TBU in overlapping clinical phenotypes of granulomatous uveitis (Q + OS).

Pattern of Tubercular Uveitis in Active Pulmonary Tuberculosis.

Ocular tuberculosis is an extra-pulmonary form of systemic Tuberculosis (TB). It is rarely found concomitant with active pulmonary tuberculosis (PTB). The aim of this prospective observational study was to evaluate the pattern of tubercular uveitis (TBU) in the patients with active PTB who attended in our Uvea clinic at NIO&H from July 2018 to December 2020. Active PTB patients who had uveitis consistent with TBU and TBU patients who were confirmed as active lung lesion were included in the study. Chest X-ray, TST, IGRA (QuantiFERON-TB Gold Test), RT PCR of aqueous fluid for tubercular bacillus, Gene Xpert TB test of sputum were done to confirm the diagnosis of ocular and primary TB. If the induration is 15 mm of TST was considered patient in this study. Among 33 patients of active PTB, 4 had TBU (12.12%). Among 48 patients of TBU, 5 had active PTB (10.41%). 13 eyes of 9 patients were affected. Mean age at presentation was 41.8 years. There were anterior uveitis in 23.00% eyes, posterior uveitis in 69% eyes and panuveitis in 7.00% eyes. Choroidal granuloma was the most common presentation of posterior uveitis (46.00%). There were more than 4 times chance to develop choroidal granuloma in patients with active PTB than extrapulmonary TB (Χ²=4.53, <0.05), TBU patients with choroidal granuloma should be evaluated meticulously for active PTB and active PTB patients should be evaluated routinely by ophthalmologist for the search of TBU.

Tubercular Uveitis in Uveitis Cases in a High TB and HIV Setting: A Prospective Cohort Study.

Purpose: The diagnosis of tubercular uveitis (TBU) is difficult. The lack of a diagnostic gold standard has contributed to challenges in determining the true prevalence and clinical predictors of TBU. We aimed to determine the proportion of TBU cases in adults with uveitis and to examine clinical features associated with TBU. Methods: A prospective cohort study of adult uveitis cases after exclusion of other specific etiologies. The diagnosis of TBU was based on a composite reference of: any clinical signs of uveitis; exclusion of other causes of uveitis; and positive QuantiFERON-Gold test, tuberculin skin test, and/or ocular TB polymerase chain reaction. Results: Of 79 cases analyzed, 49 (62%) had TBU. Female sex (P = 0.001) and chronic uveitis (P = 0.006) cases were more common in the TBU group than the non-TBU group whereas diffuse choroiditis (P = 0.010) and HIV-positive (P = 0.001) cases were less common. Choroidal granulomas (P = 0.176) and serpiginous-like choroiditis (P = 0.292) were more common in TBU group, albeit not significantly. On univariate analysis, female sex (odds ratio, 5.1; P = 0.002), negative HIV status (odds ratio, 0.2; P = 0.001), and chronic uveitis (odds ratio, 4.1; P = 0.008) were associated with TBU. A negative HIV test was associated with TBU on multivariate analysis (P = 0.049). Conclusions: A high proportion of cases had TBU. Our study did not significantly confirm some of the clinical features associated with TBU reported in other studies. Translational Relevance: Our study highlights the difficulties in determining the proportion and clinical predictors of TBU, especially in the absence of a gold standard diagnostic test.

Tubercular Episcleritis: A Review of Literature.

Episcleritis is rarely reported to be associated with tuberculosis (TB). In this review, we highlight this underreported entity and elaborate on the natural history of the reported cases in the literature. Eighteen articles were found to describe numerous cases throughout the past century. Forty patients diagnosed with tuberculous episcleritis were found in the literature. The majority of the patients presented with a latent form of TB and fewer cases were linked with active/pulmonary disease. The natural history of episcleritis was found to have chronic and recurrent attacks refractory to traditional treatment, and the most commonly reported type was the nodular form. The described cases were eventually treated by quadruple antituberculous therapy, and fortunately, recurrence after treatment completion was not documented. It is imperative to highlight such entities that may be underreported in endemic countries, as successful therapy would decrease ocular morbidity and prevent potential unforeseen tuberculous complications.

Bilateral Ocular Tuberculosis in a Child with Negative Tuberculin Skin Test (TST): A Diagnostic Dilemma.

PURPOSE: To report a case of bilateral ocular tuberculosis (OTB) in a child with negative Tuberculin skin test (TST). METHODS: Case report. OBSERVATIONS: A 12-year-old malnourished systemically asymptomatic boy presented with sudden profound loss of vision in both eyes. Dense vitritis precluded fundus visualization in right eye (RE). In left eye, fundus findings of extensive vasculitis associated with multifocal retinochoroiditis were suggestive of OTB. However, negative TST, normal chest X-ray, and gram negative bacteriuria led to confusion between endogenous endophthalmitis and OTB. Based on strong clinical suspicion and high-resolution chest tomography (HRCT) of thorax which was suggestive of TB-pneumonitis, a diagnosis of presumed OTB was made. A good response to anti-tubercular-treatment and corticosteroids, with resolution of retinochoroiditis lesions, vasculitis, and vitritis, further supported our diagnosis. CONCLUSIONS: This case highlights the importance of keeping a high index of suspicion for TB-associated uveitis in children, based on clinical findings.

Clinical features and management of presumed ocular tuberculosis: A long-term follow-up cohort study in a tertiary referral center in Brazil.

PURPOSE: To evaluate the clinical features and management of presumed ocular tuberculosis (OTB). METHOD: A prospective 3-year follow-up study of patients with ocular inflammation that performed Interferon-gamma release assay (IGRA) and tuberculin skin test (TST) was conducted in a tertiary referral center in Brazil. Patients with clinical signs highly suspect of OTB with a positive TST and/or IGRA with other causes ruled out were prescribed anti-tuberculosis therapy (ATT) during 9 months. Clinical features and treatment outcomes were recorded. RESULTS: Seventy-two patients (mean age 48.3 ± 15.7 years) were included in the study, and most were female (65.3%, n = 47). Posterior uveitis (43.1%, n = 31) was the main clinical feature. Multifocal choroiditis (25%, n = 18) was the most common choroidal involvement. Concomitant oral prednisone (45.8%, n = 33) during ATT was associated with more recurrences (p = 0.04). A significant difference (p < 0.001) between initial and final best-corrected visual acuity after ATT conclusion was observed. Cure or remission was observed in 58 (85.3%) patients that completed follow-up (n = 68). CONCLUSION: In our cohort some variation in demographics and ocular phenotypes of presumed OTB was observed. The high rates of cure or remission of our patients strongly support the ATT in presumed OTB. Oral corticosteroids during ATT were associated with higher recurrences rates.

Are the patients with drug sensitive tuberculosis screened for ocular manifestations? A five year analysis from a medical college hospital of Karnataka, India.

BACKGROUND: Early diagnosis and prompt treatment may be sight-saving in patients with Ocular Tuberculosis (TB). Patients on anti tubercular treatment (ATT) also need ophthalmological examination at the start of the treatment and monitoring for toxic optic neuropathy regularly till the completion of treatment. This study is a situation analysis of the referral rates to ophthalmologist and clinical presentations of ocular TB among patients admitted with drug sensitive tuberculosis (DS TB). METHODS: A five year record analysis (2013-2017) of patients admitted with DS TB in a medical college hospital setting was done. Demographic and clinical presentations of the patients were recorded. The details about the referral, clinical findings, any possible risk associated with ocular TB and ocular side effects of ATT were noted. Data was entered in Microsoft excel and analysed for descriptive statistics. RESULTS: Among 225 inpatients, only 72 (32%) patients were referred to ophthalmologist. The referral rates increased over the period of five years. Intra ocular TB was diagnosed among 11 (15.3%) patients. Only 5 patients among these had complained of reduced vision and others were asymptomatic. CONCLUSION: The referral of DS TB patients to ophthalmologist was sub optimal. All the DSTB cases need ophthalmic evaluation keeping in mind the possibility of ocular TB and also the adverse effects of ATT.

Recurrent Tubercular Episcleritis.

Ocular tuberculosis (TB) is one of the extrapulmonary manifestations of mycobacterium TB. Episcleritis is a rare entity that may affect patients in endemic areas of TB. In this paper, we report a case of presumed recurrent episcleritis attributed to TB. TB should be kept as a possible cause of recurrent simple episcleritis upon encountering patients with endemic backgrounds to prevent the complication sequalae and halt recurrence.

Prognosis of Ocular Tuberculosis Following Long-Term Antitubercular Therapy.

Purpose: This study presents clinical features and prognosis after long-term (12-18 months) antitubercular therapy (ATT) in patients with ocular tuberculosis (OTB) in East China, an endemic area of tuberculosis. Methods: This retrospective study reviewed data from OTB patients treated at the Eye and ENT Hospital of Fudan University from 2008 to 2018. All the patients completed a minimum follow-up of 6 months after the cessation of ATT. Results: Sixty-six patients with OTB were studied. The ocular manifestations included retinal vasculitis (51.6%), choroiditis (24.2%), panuveitis (23.2%), intermediate uveitis (7.4%), scleritis (5.3%), anterior uveitis (2.1%), and optic neuropathy (1%). Except for two patients (ATT for 6 months), all other patients (64/66, 96.97%) received ATT for at least 12 months (6 patients for 12 months, 30 patients for 15 months, and 28 patients for 18 months). Treatment in conjunction with oral corticosteroids was used in 48 patients (72.7%). The average initial best-corrected visual acuity (BCVA) was 0.8 ± 0.64 (LogMAR), which improved to 0.31 ± 0.35 (LogMAR) at the last follow-up (P < 0.05). The final BCVA was significantly associated with the initial BCVA and the duration of clinical symptoms. A complete remission of uveitis was achieved in 97% of the patients. Conclusions: This study observed a favorable prognosis with long-term ATT regimens. Patients with better baseline visual acuity and a shorter duration of clinical symptoms before diagnosis had a better prognosis.

TUBERCULOUS CHOROIDITIS IN PATIENT WITH VOGT-KOYANAGI-HARADA DISEASE.

PURPOSE: To describe a novel case of intraocular tuberculosis (TB) arising in a patient undergoing treatment for Vogt-Koyanagi-Harada disease, and to highlight the use of spectral domain optical coherence tomography for helping confirm the diagnosis and monitor treatment response. METHODS: Case report of a patient with Vogt-Koyanagi-Harada disease on prednisone, with acute clinical changes suspicious for bilateral tuberculous choroiditis. Spectral optical coherence tomography, fundus photography, and B-scan ultrasonography were all used to capture the acute lesions, and to monitor their responses after initiation of anti-TB therapy. RESULTS: New subretinal lesions arose bilaterally, as characterized by spectral domain optical coherence tomography, and appeared to regress after a first round of anti-TB therapy, thereby helping confirm the presumed diagnosis of intraocular TB. A new peripheral choroidal lesion arose shortly after temporary cessation of antimicrobial treatment, and again regressed once four-drug therapy was instituted, with no recurrent lesions thereafter. CONCLUSION: The use of multimodal imaging was instrumental in the management of a rare case of intraocular TB arising in the setting of underlying Vogt-Koyanagi-Harada disease.