Managing a recurrence of choroidal tuberculoma two years following primary therapy.

A 25-year-old female was diagnosed to have pulmonary tuberculosis two years before and had received Anti-tubercular treatment (ATT) for the same. During her initial presentation, she had extra-foveal healed choroidal granulomas (CG) [Fig. 1a] with a best-corrected visual acuity (BCVA) of 20/30 in the Left eye (LE). She recently presented with diminution of vision in her LE (BCVA – 20/200). Fundus showed reactivation of CG with an exudative retinal detachment [Fig. 1b and c]. A fresh systemic work up did not reveal active systemic tuberculosis. The mantoux test remained positive. The patient was restarted on ATT with additional oral steroid therapy. Due to poor response and steroid related side effects an intra-vitreal injection of bevacizumab was given to help in early resolution of exudation. Slow tapering of steroids was initiated. At 3 months follow up significant reduction of the exudative component with partial resolution of the granuloma was seen. After 6 months of ATT the entire fluid resolved, the granuloma showed regression [Fig. 1d] and the BCVA improved to 20/40.

Figure 1

(a) Initial Fundus picture of the left eye during the primary presentation showing healed choroidal granulomas (CG) infero-temporal to the fovea. (b and c) Two years after her initial presentation, the patient had recurrence over the preexisting CGs characterized by exudative retinal detachment (arrow marks) spreading laterally and inferiorly to the lesion. (d) With multimodal treatment approach including the effective use of intra-vitreal anti vascular endothelial growth factor (bevacizumab) the exudation resolved over a period of three months

Vascular endothelial growth factor (VEGF) expression is found to be increased at the site of an active tubercular CG. The up-regulation of VEGF occurs due to the induced production by the on site cytokines and/or as a secondary response to tissue hypoxia caused by inflammatory vascular obstruction.[1] The VEGF in turn accelerates angiogenesis and exudation at the target site which is the highly vascularized chorio-retinal juncture as in our case. Thus, anti-VEGF agents can promote resolution of exudation. The effective use of anti-VEGFs in tubercular granuloma have been documented before.[23]

It is difficult to say whether anti-VEGF assisted in resolution of the tubercular granuloma. However, it definitely seems to have enhanced the resolution of the exudative component. We also want to highlight the importance of follow up in cases of resolved CGs. Other than Choroidal neo-vascularization, recurrence can also be seen in large lesions.

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Conflicts of interest

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