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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



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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)