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| CASE REPORT |
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| Year : 2022 | Volume
: 9
| Issue : 1 | Page : 14-17 |
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Presumed unilateral quiescent multifocal tuberculous choroiditis
Yewande Olubunmi Babalola1, Emmanuel Olu Megbelayin2
1 Department of Ophthalmology, University College Hospital, University of Ibadan, Ibadan, Nigeria
2 Department of Ophthalmology, University of Uyo Teaching Hospital, University of Uyo, Uyo, Nigeria
| Date of Submission | 10-Jun-2022 |
| Date of Acceptance | 06-Oct-2022 |
| Date of Web Publication | 11-May-2023 |
Correspondence Address:
Dr. Yewande Olubunmi Babalola
Department of Ophthalmology, University College Hospital, University of Ibadan, Ibadan
Nigeria
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/erj.erj_5_22
A 43-year-old housewife presented to the retina clinic with a 5-year history of poor vision in the left eye. There was no antecedent history of trauma. At presentation, the best-corrected visual acuity was 6/5 and counting fingers in the right and left eye, respectively. Examination of the anterior segment was essentially normal in both eyes. Fundus examination with binocular indirect ophthalmoscopy of the right eye revealed a normal fundus, whereas the left eye had a pale optic disc, widespread hyperpigmented scars some located subvascular, subretinal fibrosis, occluded vessels, and macular atrophic changes. The systemic examination was essentially normal. There was a positive history of previous treatment for pulmonary tuberculosis (TB) about 5 years before presentation at the retina clinic. Due to the ocular findings in the left eye and a history of pulmonary TB, a diagnosis of left-healed presumed tuberculous choroiditis was made.
Keywords: Choroiditis, pulmonary tuberculosis, subvascular scars<
How to cite this article:
Babalola YO, Megbelayin EO. Presumed unilateral quiescent multifocal tuberculous choroiditis. Egypt Retina J 2022;9:14-7 |
| Introduction | |  |
Ocular tuberculosis (TB) is a rare manifestation of TB which affects all ocular structures. It is a disease of great public health significance caused by mycobacteria TB. It involves the choroid and retina presenting as posterior uveitis, multifocal choroiditis, serpiginous choroiditis, retinal vasculitis, choroidal tubercles or tuberculomas, macula edema, and exudative retinal detachment.[1],[2],[3] Tubercular choroiditis is said to be the most common presentation of ocular TB.[4] Intraocular TB is an uncommon diagnosis in Nigeria; hence, there is a paucity of data on related cases. A study on ocular TB in Benin city had a prevalence of tuberculous choroiditis at 1.1%.[5]
Tubercular choroiditis could be serpiginous or multifocal in nature and could occur unilaterally or bilaterally. Multifocal tuberculous choroiditis appears as florid, yellowish lesions typically at the posterior pole and has nondiscrete borders in the active phase which eventually become pigmented when scarred.[4] Serpiginous tuberculous choroiditis lesions may be noncontiguous to the optic disc, have elevated edges, and eventually become confluent with elevated edges demonstrating a wavy pattern with central healing.[6] Other clinical features of tuberculous choroiditis include inflammatory cells in the anterior chamber, mutton-fat precipitates, Busacca and Koeppe nodules, posterior synechiae, and complicated cataract.
| Case Report | | |
A 43-year-old housewife presented with a 5-year history of poor vision in the left eye. The loss of vision was gradual in onset. There was neither antecedent history of trauma nor entry of any foreign body. She gave a positive history of redness at the onset of symptoms but no history of photophobia or tearing. There was no history of floaters, flashes of light, metamorphopsia, neither nyctalopia. She had no visual complaints in the right eye.
The patient is neither a known hypertensive, diabetic, asthmatic, nor peptic ulcer disease patient. Our patient gave a history of long-term treatment for chronic cough associated with weight loss and blood-stained sputum production 5 years previously. She received treatment for TB for 9 months after three sputum samples were positive for TB. Her spouse who is military personnel had earlier been treated for pulmonary TB for 9 months a few months before she developed the symptoms of cough, weight loss, and hemoptysis. She had neither history of joint pain, back pain, nor skin lesions.
General examination revealed a middle-aged woman not in any obvious distress, afebrile, not pale, anicteric with good hydration status, and no pedal edema. On examination of the chest, the respiratory rate was 20 cycles per minute with vesicular breath sounds; there were neither crepitations nor rhonchi were present. Examination of the central nervous, cardiovascular system, and abdomen was essentially normal. The best-corrected visual acuity was 6/5 and counting fingers, respectively, in the right and left eyes. The anterior segment examination was essentially normal with both anterior chambers devoid of inflammatory cells.
Binocular indirect ophthalmoscopy of the right eye revealed a pink disc with a cup–disc ratio of 0.3, normal macula and vessels, and flat retina with no peripheral retinal lesions present [Figure 1]. Findings on examination of the left fundus were a slightly pale disc with a cup–disc ratio of 0.3, widespread hyperpigmented chorioretinal scars, subvascular or perivascular choroidal scars, and subretinal fibrosis with widespread occluded and obliterated vessels present more in the periphery, a flat retina and no active, treatable peripheral retinal lesions [Figure 1] and [Figure 2]. Optical coherence tomographic scan of the right eye was normal, whereas the fovea of the left eye revealed alteration of the foveal contour with disorganization and thinning of the retinal layers with backshadowing from scarring and chorioretinal atrophy [Figure 3]. | Figure 1: The fundus pictures of the normal right fundus. The left fundus photo shows a pale disc with hyperpigmented chorioretinal lesions more on the nasal retina, subvascular pigmented lesions along the superotemporal, inferotemporal arcades, and at the macula
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 | Figure 2: The left fundus photograph with a clearer view of the nasal retina of the left fundus and the hyperpigmented multifocal chorioretinal scars, generalized chorioretinal atrophy, and occluded vessels
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 | Figure 3: The normal right optical coherence tomographic scan and in the left altered foveal contour, disorganization of the retinal layers, epiretinal membrane, RPE irregularities, and backshadowing. RPE: Retinal pigment epithelium
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Other differentials considered include old settled retinal detachment, previous trauma, laser scars, unilateral retinitis pigmentosa, and old central retinal arterial occlusion. These differentials were ruled out as the history was a negative prior history of sudden visual loss, prior trauma, nyctalopia, or exposure to laser panretinal photocoagulation. The pathognomonic subvascular scars combined with prior history of contact with a case of and subsequent treatment for pulmonary TB all pointed at healed tuberculous choroiditis.
An assessment of left inactive unilateral multifocal choroiditis most likely secondary to TB was made. The chest was clinically clear. As our patient had neither chest signs nor symptoms, a chest radiograph was not indicated. Treatment was not recommended as there was no active inflammation. The patient was counseled on diagnosis, the poor visual prognosis for the left eye, and precautionary and protective measures for the right eye. A new pair of spectacles was prescribed and she was scheduled for regular follow-up visits.
| Discussion | | |
The hyperpigmented scars in the left fundus of this patient and the prior history of treatment for TB at the onset of ocular symptoms were the leading signs to clinching the diagnosis. Her general and chest examinations were essentially normal with a lack of constitutional signs and symptoms of active disease. The hyperpigmented scars were subvascular in nature which is characteristic of TB.[7] This prompted us to ask for a history of treatment for chronic cough or TB which she answered in the affirmative. This was further confirmed by her narrative of having a chest radiograph done and three early morning sputum samples collected which were positive which was the premise of antituberculous therapy for 9 months.[8] This coincided with the period of initial onset of ocular symptoms in the left eye.
In addition, the presence of ghost vessels, chorioretinal atrophy and fibrosis, optic atrophy, and macular scarring were in keeping with choroiditis.[3] Macular scarring in TB is a known cause of visual impairment in TB alongside vitreous hemorrhage and complicated cataract.[9] Optic atrophy may also occur in ocular TB as a result of the choroidal extension.[10] These are the most likely causes of visual loss in the affected left eye of our patient. A pigmented scar was also present at the macula. Optical coherence tomography scan revealed atrophy of the outer retinal layers and retinal pigment epithelium and choroidal thinning which are characteristic sequelae of healed tuberculous choroiditis.[11],[12] Occlusive vasculitis which is pathognomonic of TB is probably responsible for the ghost vessels and occlude vessels present.[1]
Typically, tuberculous choroiditis may be bilateral or unilateral although more commonly bilateral.[1],[3] This patient had a unilateral fundal affectation which may be one of the factors for not presenting at the acute phase of the disease. Antituberculous therapy was given to our patient for pulmonary TB and this may have led to the resolution of the left fundal lesions although the ocular inflammation was not diagnosed in the acute phase.[4],[8],[9] Ocular TB may also occur in isolation or with systemic involvement commonly pulmonary TB.[1],[9],[13] Apparently, the index patient had multisystemic involvement as the diagnosis of presumed tuberculous choroiditis is retrospective based on the subvascular characteristic of the multifocal scars and the prior history of treatment for pulmonary TB.
A case of tuberculous choroiditis initially diagnosed with serpiginous-like choroiditis and treated as such with poor response to steroids and later confirmed with relevant tests like the TB-quantiferon test has been described in the literature. The presenting complaint of poor vision was the same as this index patient.[14] Presentation of tuberculous choroiditis may be with acute complications such as choroidal neovascular membrane and cystoid macula edema but our patient had only scarring and atrophic changes at the macula as seen on OCT scans.[1],[11],[15]
Multimodal imaging is a modern, universal approach to the diagnosis of TB. Fundus autofluorescence is a useful tool in the diagnosis of tuberculous choroiditis, especially in detecting active disease; active lesions will hyperautofluoresce, whereas scarred portions will hypoautofluoresent. Optical coherence angiography is also beneficial in assessing the activity of the choroidal lesions.[11] These various diagnostic tools were not available in our center and there were no symptoms or signs of active disease, the diagnosis was mainly based on clinical findings and the elicited history from the patient.
The mainstay of treatment after diagnosis of ocular TB is the use of antituberculous therapy and the use of steroids to curtail inflammation.[1],[9],[13] Anti-vascular endothelial growth factors may be required in patients who develop active choroidal neovascular membranes.[15] Our patient was in the quiescent phase at diagnosis; hence, active treatment was not indicated in this index case.
| Conclusion | | |
Ocular choroiditis although rare may occur in patients with TB. The presentation of tuberculous choroiditis may be in isolation or with multisystem involvement. A high index of suspicion is required in patients presenting with uveitic symptoms and patients with TB of other sites with ocular complaints. Tuberculous choroiditis especially of the granulomatous variety should be considered in patients presenting to uveitis and retina clinics. Routine ocular examinations may be recommended for patients diagnosed with TB for early diagnosis and prompt treatment of ocular involvement and sequelae.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
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