A cute bilateral conjunctivitis with nasooral involvement: A rare manifestation of tuberculosis.

Ocular tuberculosis (TB) is rare.[1] TB most commonly presents as uveitis and phlyctenular conjunctivitis. Conjunctival TB is a well-established clinical entity and may appear as an ulcerative lesion, military tubercle, hypertrophic granulation, lupus, or pedunculated mass.[23] We report a case of acute nodular bilateral conjunctivitis associated with inflammation of the mouth and the nostril. However unlike phlycten, these nodules were multiple, bilateral, and associated with intense conjunctival congestion. Further evaluation of the patient revealed a mediastinal mass that later proved to be TB on biopsy pathology. This is a rare manifestation of conjunctival inflammation with stomatitis and vestibulitis in a case of mediastinal tuberculosis. To the best of our knowledge such presentation has never been reported.

A 16-year-old girl presented with complaints of redness, watery discharge, and moderate pain in both the eyes since 2 weeks with discomfort of the mouth and nose. She was treated with topical moxifloxacin and carboxymethyl cellulose eye drops with no improvement. Systemically, she complained of episodes of mild fever and loss of weight in the past few months.

Facial examination revealed bilateral red eyes [Figs. 1 and 2], erythema of the left nostril with crusts and mild red lips with crusting [Fig. 3]. The visual acuity was 6/6 in both eyes. Examination of showed intense conjunctival congestion with multiple, elevated, flat topped limbal nodules in both the eyes. The patient was referred to a dermatologist and ENT surgeon. Both the dermatologist and ENT surgeon made a diagnosis of nonspecific inflammation and advised medical management. High-resolution chest CT scan revealed confluent necrotic mediastinal nodes in the right paratrechial and subcarinal locations. [Fig. 4] She underwent computed tomography-guided biopsy of the mediastinal mass. Histopathology revealed granulomatous inflammation with the presence of 20% acid fast bacilli. The culture grew Mycobacterium tuberculosis. The conjunctivitis resolved with topical prednisolone acetate 1% eye drops and systemic condition improved with oral anti-TB regime. There was no recurrence when followed up at 6 months.

Figure 1

Right eye (RE) conjunctival congestion with perilimbal nodules

Figure 2

Left eye (LE) showing conjunctival congestion with large perilimbal nodules

Figure 3

Erythema of the left nostril with crusts and mild red lips with crusting

Figure 4

High-resolution CT chest showing mediastinal mass

The causation of the conjunctival and oral mucosal inflammation is likely due to the systemic disease, as no other pathology could be found and also there were no recurrences after the treatment. We believe this presentation is likely to represent a hypersensitivity reaction to systemic TB and may share some similarity with the cases described as atypical SJS or Fuch's syndrome associated with mycoplasma pneumonitis[45] possibly having similar pathophysiology. In countries like India where TB is rampant being aware of such unusual presentation helps in the earlier detection of systemic TB.

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