Tuberculosis presenting as posttraumatic panophthalmitis.

Panophthalmitis is one of rare manifestations of tuberculosis described in atypical situations such as children, immune compromised patients, or drug abuse. The present report describes the first case of tubercular panophthalmitis developing after trauma in an otherwise healthy adult patient. A 46-year-old female patient presented with corneal infiltrate and endophthalmitis that developed after an injury to right eye with wooden object. Corneal scrapings and vitreous tap were sterile. The patient did not improve with antibiotics and developed panophthalmitis. On evisceration of the painful blind eye, histopathology showed the presence of granulomatous inflammation and acid-fast bacilli. The patient had no other systemic focus of tubercular infection. The patient was managed with anti-tubercular therapy for 6 months. Atypical presentations of tuberculosis like panophthalmitis pose a difficult problem in diagnosis as well as treatment. Direct inoculation of bacilli during trauma is a rare source of infection. This case report presents unusual development of tubercular panophthalmitis following direct inoculation of bacilli during trauma. Ocular tuberculosis should be considered in differential diagnosis of posttraumatic endophthalmitis and panophthalmitis, especially in endemic regions like India.

Introduction

Ocular manifestations of tuberculosis are usually secondary to systemic disease or due to local invasion from active sinusitis or meningitis. Primary ocular involvement is usually less frequent occurring through either cornea or conjunctiva and is mostly seen in children.[1] Usually, corneal and conjunctival involvement in tuberculosis occurs as hypersensitivity reaction in the form of phlyctens. Panophthalmitis is a rare manifestation of ocular tuberculosis.[2] Direct invasion of the conjunctiva or cornea by tubercular bacilli after trauma aggressively developing into panophthalmitis has not been reported so far. This report describes the first case of panophthalmitis developing in a healthy adult female patient following trauma that proved to be tubercular in origin.

Case Report

A 46-year-old female patient presented with chief complaints of painful, sudden diminution of vision in right eye, following trauma by a wooden stick 3 days prior. On presentation, visual acuity in the affected eye was the only perception of light with an inaccurate projection of light rays whereas visual acuity in the left eye was +0.2 LogMAR. Ocular examination showed purulent conjunctival discharge with matting of eyelashes, sealed corneal perforation with corneal infiltrates, and the anterior chamber was full of the exudates [Figure 1a]. The ultrasonography of the right eye showed dense vitreous exudates and retina was in suggesting the diagnosis of endophthalmitis. Corneal scrapings and conjunctival swabs sent for bacterial and fungal smears were negative. Diagnostic vitreous tap for bacterial and fungal smears was also done, and intravitreal antibiotics (vancomycin 1 mg in 0.1 ml and ceftazidime 2 mg in 0.1 ml) were administered. The patient was started on fortified vancomycin (50 mg/ml) eye drops 1 hourly; cefazolin (50 mg/ml) eye drops 1 hourly along with natamycin 5% eye drops 1 hourly in the right eye. The vitreous tap was also negative for bacterial and fungal smears. However, the patient developed panophthalmitis in 24 h with positive t-sign and thickened retinochoroid on ultrasonography [Figure 1b] that led to the painful blind eye. Considering the diagnosis of panophthalmitis and painful blind eye, the patient was counseled for evisceration. After obtaining informed written consent, evisceration was done, and the excised ocular tissue was sent for histopathological examination. Histopathological examination showed the presence of lymphocytic infiltrate with caseous necrosis suggesting granulomatous inflammation [Figure 1c]. Staining for acid-fast bacilli was positive [Figure 1d]. Polymerase chain reaction (PCR) of the corneal tissue also showed positivity for the tubercular antigen. The patient was investigated for any systemic focus of tubercular infection, but the results were negative. There was no past history of tubercular infection or contact. The patient was started on anti-tubercular therapy. After follow-up of 6 months, the patient was asymptomatic, and there was no systemic manifestation of tuberculosis.

Figure 1

(a) Anterior segment picture of the patient showing dense, full thickness corneal infiltrates, conjunctival chemosis and congestion, anterior chamber full of exudates and an area of corneal melt; (b) ultrasonography B-scan of the eye showing exudates in vitreous cavity, thickened retinochoroid, and positive t-sign suggestive of panophthalmitis; (c) haematoxylin eosin stained section of the enucleated eyeball showing eosinophilic caseous necrosis with lymphocytic infiltrate; (d) smear showing acid-fast bacillus in the section

Discussion

Ocular tuberculosis has varied percentage of association with systemic disease (0–100%).[34] Corneal involvement in tuberculosis is usually secondary to endogenous infection as a hypersensitivity reaction in the form of phlyctenular conjunctivitis.[5] Interstitial keratitis or sclerokeratitis are the other forms of corneal involvement in tuberculosis. Intra-ocular tuberculosis can have varied presentation in the form of a subretinal abscess, granulomatous uveitis with scleritis, and choroidal mass with panuveitis.[6] Tubercular panophthalmitis is, however, a rare manifestation of the disease. Atypical presentations in ocular tuberculosis are usually seen in patients with immune compromised status. Tuberculosis presenting with hypopyon is rare, and only one case with pigmented hypopyon has been described.[7] Tubercular infection presenting as acute tubercular panophthalmitis is usually seen in children[8] or immune compromised patients.[2] There are only few case reports describing tubercular endophthalmitis or panophthalmitis.[68910111213] An immunocompromised patient has been described with prominent iris nodules as the initial manifestation of localized panophthalmitis. Despite rigorous topical, intracameral and systemic therapy, the disease progressed and needed enucleation due to scleral rupture.[11] The organism confirmed on culture was Mycobacterium avium-intercellulare. An unusual presentation of tubercular endophthalmitis in the form of calcified vitreous mass presenting with leukocoria has also been described.[12] Tubercular etiology was proved only after histopathology of the enucleated eyeball. Another article has described tubercular panophthalmitis developing in an atypical situation in a patient with drug abuse.[11] Diagnosis of ocular tuberculosis is a challenging situation as considered by various authors.[1314] Rapidly progressive posttraumatic tubercular panophthalmitis in otherwise healthy adult patients has not been described earlier. This case report is unusual in the sense that a posttraumatic rapidly progressive panophthalmitis proved to be tubercular in etiology with no systemic evidence of the disease. This case report also shows that diagnosis of tuberculosis in atypical situations poses a difficult problem. Histopathology and PCR were conclusive of tuberculosis in the present case. We conclude that ocular tuberculosis should be considered in differential diagnosis of posttraumatic endophthalmitis and panophthalmitis, especially in endemic regions like India.

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Conflicts of interest

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