Tuberculosis Marco Coassin, Sylvia Marchi, Erika Mandarà, Valentina Mastrofilippo, Anna Maria Soldani and Luca Cimino Ocular Immunology Service Ophthalmology Unit: Director Luigi Fontana

First Presentation – General History 49 year old Caucasian female headache, musculoskeletal pain drowsiness and nausea nurse in an hospital no other risk factors immunocompetent

First Presentation - Differential Diagnosis Viral encephalitis (HSV, VZ, EBV, CMV…) Bacterial meningoencephalitis (TB, Syphilis, Brucellosis…) Hospitalized in the Dept. of Neurology, started therapy immediately, while waiting for test results

First Presentation – Lab Tests chest X-Ray blood tests to rule out systemic infections brain MRI lumbar puncture EEG Mantoux skin test

First Diagnosis Viral or bacterial encephalitis

Treatment intravenous acyclovir (10 mg/Kg TID) intravenous ceftriaxone (1 gr TID) oral prednisone (25 mg/day)

Lab Results Chest X-Ray: negative Blood tests: negative Mantoux skin test: negative Brain MRI: meningitis with no encephalic lesions EEG: suggestive of meningoencephalitis Lumbar puncture: lymphatic pleiocytosis, PCR negative for viruses  STOP of acyclovir

From Neuro to Ophtho… Eye examination was requested by Neuro only one week after admission, because the patient was complaining of red eyes

Ocular Involvement mild conjunctival injection in both eyes anterior segment was otherwise unremarkable (no cells/flare) BCVA was 20/70 OU IOP 14 OU fundus: bilateral papillitis and whitish chorioretinal lesions  STOP corticosteroids

First Presentation – Ocular Examination

First Presentation - Fundus papillitis disk hemorrages whitish chorioretinal granulomas

First Presentation - FLA

First Presentation - FLA and ICG Hyperfluorescence at optic disk head Fluorescence blockage from hemorrages Hypofluorescence from chorioretinal lesions

granulomatous posterior Uveitis New Diagnosis granulomatous posterior Uveitis

DD of granulomatous posterior Uveitis TB Syphilis Vogt-Koyanagi-Harada Sarcoidosis

Additional Lab Results Quantiferon TB-Gold test negative Re-do RPR and TPPA for Lues negative PCR for TB on CSF positive

granulomatous posterior Uveitis due to Tuberculosis Final Diagnosis granulomatous posterior Uveitis due to Tuberculosis

Anti-TB Therapy Rifampicine 600 mg/day Isoniazide 300 mg/day Ethambutol 15 mg/day/Kg Low-dose oral steroids

Follow up – After 1 Month

Follow up – After 1 Month Papillitis improved Smaller disk hemorrages Reduced halo around chorioretinal lesions

Final examination – After 3 years

Final examination – After 3 years Pink optic nerve head Chorioretinal scars/atrophy Final VA 20/20 OU

Conclusion Some rare forms of TB infections may assume an acute presentation and specific test could be negative at first. In the cerebral forms of TB the eyes could be involved secondarily Diagnosis from eye samples can be difficult Clinical examination plays a key role in the diagnosis of TB uveitis Consider TB in patients with risk factors (here: nurse)