1. A CASE OF INFECTIOUS AND AUTOIMMUNE DISEASE COEXISTENCE Elisabetta Miserocchi MD Department of Ophthalmology and Visual Sciences University Hospital San Raffaele, Milan, Italy

2. CLINICAL CASE 36 year old woman, Caucasian Occupation: nurse in a nursing home Chief Complain 12/2005: - Loss of vision OD>OS lasting 5 months

3. PAST OCULAR HISTORY 7/05: loss of vision OD>OS Previous hospitalization in another center: -Diagnosis of bilateral optic disc edema -Neurologic consult: negative (CT, MRI, LP) -Treatment with oral steroids (prn 75 mg) for 5 months : no visual improvement

4. EXAMINATION VA: OD: CFOS: 4/10 Anterior Segment OU: Normal IOP: 13 mmHg Fundus:

5. VISUAL FIELD RETINAL VASCULITIS

6. PAST MEDICAL HISTORY 3/05: Pneumonia with blood coughing treated with systemic antibiotic 6/05: Headache, constant and frontal Obesity Hypercholesterolemia REVIEW OF SYSTEM

7. ASSESSMENT Bilateral optic neuropathy OD>OS Bilateral retinal vasculitis ?

8. NEW WORK-UP IN OUR OPHTHALMOLOGY DEPT Chest CT scan: pleural thickening Brain and orbit MRI: normal Laboratory tests: HLA-A29 positive PPD + 50 mm induration Neurophthalmology consult: presumed tubercular optic neuropathy Infectious disease consult: anti-tubercular treatment was began

9. Follow up 3/06 visual acuity improvement OD: 4/10OS:9/10 6/06 Vitriitis OU Corticosteroids + CSA added

10. 4/07 Visual acuity restoration OD: 9/10OS:10/10 Normal visual field Late occurrence of typical chorio-retinal lesions

11. FINAL DIAGNOSIS Presumed tubercular optic neuropathy -response to anti-TB treatment alone -Restoration of visual acuity and visual field Birdshot retinochoroidopathy -Bilateral vitritis, retinal vasculitis, late occurrence of typical chorioretinal lesions -Response to corticosteroids treatment -HLA-A29 +

12. Our take home message Diagnosis of ocular tuberculosis is often presumptive. The absence of clinically evident systemic TB does not rule out the possibility of ocular TB. TB is increasing in Italy in the last 10 years: PPD test should be tested in all uveitis pts. Different pathogenetic mechanisms (infectious and autoimmune) may coexist and complicate the clinical spectrum of ocular inflammation.