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

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

3. 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

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

5. First Diagnosis
Viral or bacterial encephalitis

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

7. 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

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

9. 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

10. First Presentation – Ocular Examination

11. First Presentation - Fundus
papillitis
disk hemorrages
whitish chorioretinal granulomas

12. First Presentation - FLA

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

14. granulomatous posterior Uveitis
New Diagnosis
granulomatous posterior Uveitis

15. DD of granulomatous posterior UveitisTB
Syphilis
Vogt-Koyanagi-Harada
Sarcoidosis

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

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

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

19. Follow up – After 1 Month

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

21. Final examination – After 3 years

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

23. 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)