1. Case presentation By :Saad Aldahmash,MD

2. History A 24 years old Saudi young man came to KKESH E.R on January 2008 ( 3 months) wih Hx of : *redness on –off OD for 1 year. *gradual decrease in VA OD over the last 1 year. *Past ocular Hx was unremarkable. *Past medical and surgical Hx was unremarkable.

3. Family, social History *His youngest brother died at age of two years because of chronic cough. * He is living in Riyadh in a small house acomodating 12 persons.

4. He was Examined at that time at KKESH E.R : *VA … OD 20/70 OS 20/20 *IOP… OD 18 mmHg. OS 16 mmHg. *SLE …OD: mutton fat KPs, +3 cells, vitritis. OS :quiet eye. B-scan done, showed :only vitreous haze in OD. He was diagnosed at that time as a case of : *unilateral Granulomatous panuveitis OD.

5. *They started to investigate him. *The patient lost his follow up, didn’t show.

6. The patient came again to the E.R at KKESH last week with a Hx : *Increased Pain,redness and marked reduction of VA in OD. *the patient give a Hx of recent weight loss.

7. Examination : VA … OD HM OS 20/20 IOP… OD 56 mmHg. OS 18 mmHg. SLE … OD: corneal edema,scleritis with scleral melting,mutton fat KPs,shallow A/C, +4 cells, 360 post. Synechiae, limbal lesion, no view to post. Pole.

12. SLE… OS : unremarkable. B-scan OD : significant vitreous haze. UBM : showed ciliary body lesion extending from 3 o’clock to 8 o’oclock position, 360 synaechial angle.

15. *PPD test ( 5 iu): 10 mm enduration. *ESR : 67 mm/hr. *CRP : Positive. *ACE : normal value. *HIV, TPHA,RPR : Negative. *Iron deficiency anaemia. *CBC: wbc 13.6 Hb 9.7 mg/dl. *High serum urea and creatinine, low K. *CT chest: multiple foci of inactive (most likely)TB granulomas.

16. The Diagnosis : *Tuberculous panuveitis. *Ciliary body, limbus, scleral Tuberculous granuloma. * Secondary angle closure glaucoma.

17. Ocular Tuberculosis review *Actually,TB can affect any structure of the eye and adnexia. *Ocular structures are highly vascularized, high affinity for TB bacilli. *Diagnosis of ocular TB is very challenging. * Most of the times no associated concurrent active systemic disease.

18. Review of the litreature *conjunctival granuloma. *chronic conjunctivitis. *Periorbital osteomyelitis. *orbital granuloma with enophthalmos. *Orbital Psudotumor like picture. *Endogenous endophthalmitis. *panophthalmitis. *orbital abscess.

19. *Preseptal cellulitis. *Retinoblastoma like picture. *Dacryoadenitit. *Dacryocystitis. *NLD obstruction due to nasal granuloma. *Primary lid tuberculoma. *Myositis. *Phlectenulosis.

20. *Scleritis. *keratitis, PUK. *spontaneous globe perforation. *Anterior uveitis ( granulomaous, non granulomatous ). *Angle, ciliary body granuloma. *Vitritis. *papillitis.

21. *Optic disc tubercle. *Primary vascular occlusion without vasculitis. *vasculitis. *multifocal choroiditis,chorioretinitis,retinitis. *Choroidal tuberculoma without choroiditis ( similar to metastatic choroidal lesions).

22. WHO *Because of the increase of HIV No of patients. *emergence of multidrug resistant strains. *poor countries where TB is endemic(or epidemic). *easy migration between countries. *late diagnosis (presentation) because of the masking effect of some antibiotics.

23. *All previous factors led to an increase in the TB incidence all over the world. *TB nowadays, not as before in India,Africa,Indonesia….. It is becoming not uncommon infection in the US, Europe, also.

24. TB in KSA *There were some reports from madina area of multidrug resistant Mycobacteria tuberculosis. *Early diagnosis is very important to decrease the morbidity, mortality, avoid high bacterial load of mycobacterium tuberculosis which make eradication more difficult.

25. Conclusion *TB can mimic many ocular,adnexal pathologies. * TB must be in the differential diagnosis of any inflammations,tumors and vascular disorders affecting the globe and it’s adnexa.

26. Thank you