Coexistent miliary tuberculosis of choroid and tubercular panuveitis: a report.

Case Report

A 27-year-old man presented with progressively worsening vision in his left eye for 1 month. He was a known case of tubercular meningitis on four drugs antitubercular medication (ATT). He had 6/6 vision in the right eye with an unremarkable anterior segment. Left eye had perception of light. Fig. 1a and b depict slit lamp evaluation of active panuveitis in the left eye. An ultrasound examination followed by [Fig. 1e] was performed due to poor view of the fundus, which revealed vitritis, thickened retinochoroidal complex and attached retina consistent with panuveitis. Fig. 2 shows choroidal miliary tubercles in the right eye. Fundus fluorescein angiography revealed active choroiditis lesions [Fig. 3]. Polymerase chain reaction (PCR) performed on the aqueous aspirate from the left eye revealed MPB64 gene and nested-PCR (nPCR) detected IS6110 region specific for Mycobacterium tuberculosis (MTB) [Fig. 4]. High resolution computerized tomography of the chest revealed tubercular miliary mottling in both lungs.

Figure 1

(a, b) Pre-operative slit lamp photo of left eye showing corneal edema, extensive peripheral anterior synachae, altered iris texture and complicated cataract, (c, d) show post-operative slit lamp photo at 1 and 2 months follow-up respectively, (e) U/s of left eye showing vitritis with thickened retinochoroidal complex and attached retina

Figure 2

Color fundus montage photograph showing multiple, well-defined, discrete, yellowish choroidal lesions in all quadrants, a sine qua non feature of miliary tubercles of the choroid

Figure 3

Fundus fluorescein angiography showing early (a) hypofluorescence (arrows) followed by late (b) hyperfluorescence (arrows) consistent with active choroiditis lesions

Figure 4

Agarose gel electro photogram showing the identification of Mycobacterium tuberculosisby polymerase chain reaction targeting MPB64 and IS6110 genes

Patient was advised to continue ATT and lensectomy with vitrectomy was performed in the left eye. Extensive choroidal tubercles were noted during surgery. Figs. 5 and 6 show progressive resolution of the choroiditis lesions at 1 and 2 months follow-up respectively in the right eye with vision maintained at 6/6. Left eye had best-corrected visual acuity of counting fingers with a hazy media, dense epiretinal membrane, scarring at fovea and attached retina [Fig. 7] at 2 months. Fig. 1c and d reveal anterior segment findings in the left eye at 1 and 2 months respectively.

Figure 5

Color fundus montage photograph showing partial resolution of choroidal tubercles at 1 month follow-up

Figure 6

Color fundus montage photograph showing significant resolution of choroidal tubercles at 2 months follow-up

Figure 7

Color fundus image at 2 months post vitrectomy in left eye

Discussion

Ocular tuberculosis has myriad presentations.[1] We present a case of disseminated tuberculosis with coexistent choroidal miliary tubercles in one eye and tubercular panuveitis in the other eye. Identification of specific genes by nPCR for MTB confirmed the diagnosis. Serial photographs over 2 months revealed significant resolution of the choroidal lesions without scarring. Mehta has recently published photographic and optical coherence tomography based healing patterns of choroidal tubercles.[2] However, serial photographic documentation of this disease entity is not available widely. Our case shows two different presentations occurring simultaneously in the two eyes from the same patient that is rarely reported.