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A CASE OF INFECTIOUS AND AUTOIMMUNE DISEASE COEXISTENCE

This clinical case study presents a 36-year-old nurse with a history of vision loss, bilateral optic neuropathy, and retinal vasculitis. The patient was diagnosed with presumed tubercular optic neuropathy and birdshot retinochoroidopathy, and showed improvement with anti-tubercular treatment and corticosteroids. The study highlights the importance of considering ocular tuberculosis in uveitis patients and the potential coexistence of infectious and autoimmune mechanisms in ocular inflammation.

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A CASE OF INFECTIOUS AND AUTOIMMUNE DISEASE COEXISTENCE

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  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: CF OS: 4/10 • Anterior Segment OU: Normal • IOP: 13 mmHg • Fundus:

  5. RETINAL VASCULITIS VISUAL FIELD

  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: 4/10 OS:9/10 • 6/06 Vitriitis OU • Corticosteroids + CSA added

  10. 4/07 Visual acuity restoration OD: 9/10 OS: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.

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