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Tuberculosis

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

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Tuberculosis

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  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 yearoldCaucasianfemale • headache, musculoskeletal pain drowsiness and nausea • nurse in an hospital • no otherriskfactors • immunocompetent

  3. First Presentation - DifferentialDiagnosis • 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. OcularInvolvement • 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. New Diagnosis granulomatousposterior Uveitis

  15. DD of granulomatousposterior Uveitis • TB • 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. FinalDiagnosis granulomatousposteriorUveitis 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. Finalexamination – After 3 years

  22. Finalexamination – 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)

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