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Paradoxical worsening of tuberculous chorioretinitis in a Chinese gentleman.

Siantar RG, Ho SL, Agrawal R - J Ophthalmic Inflamm Infect (2015)

Bottom Line: However, he developed paradoxical worsening 2 months after initiation of therapy.He was continued on ATT, oral steroids and intravitreal amikacin with resolution of the chorioretinal lesion subsequently.Clinicians should strongly consider starting oral steroids concurrently with ATT when managing ocular tuberculosis.

View Article: PubMed Central - PubMed

Affiliation: Department of Ophthalmology, Tan Tock Seng Hospital, Singapore, 308433 Singapore.

ABSTRACT
We report a case of paradoxical worsening of tuberculous chorioretinitis after initiation of anti-tuberculous therapy (ATT). The patient had left panuveitis with tuberculous chorioretinitis and was started on systemic ATT and oral steroids a week later. However, he developed paradoxical worsening 2 months after initiation of therapy. He was continued on ATT, oral steroids and intravitreal amikacin with resolution of the chorioretinal lesion subsequently. Ocular tuberculosis often poses a diagnostic challenge, and clinicians should be aware of the possibility of paradoxical worsening despite appropriate ATT. Clinicians should strongly consider starting oral steroids concurrently with ATT when managing ocular tuberculosis.

No MeSH data available.


Related in: MedlinePlus

a, b Fundus photos of left eye showing vitritis, vasculitis and chorioretinitis superior to the macula
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Fig1: a, b Fundus photos of left eye showing vitritis, vasculitis and chorioretinitis superior to the macula

Mentions: A 50-year-old man with past medical history of diabetes mellitus presented with 1 week history of left eye blurring of vision and mild discomfort. His Snellen visual acuity was 6/7.5 in the right eye and 6/15 in the left eye. Anterior segment examination revealed signs of uveitis with multiple keratic precipitates, anterior chamber cells 1+ and retrolental cells 2+. Fundus examination showed significant vitritis, vasculitis and a well defined yellowish-white chorioretinal lesion superior to the macula (Fig. 1a, b). Anterior and posterior segment examination of the right eye was normal. He underwent a vitreous tap which identified mycobacterial DNA via polymerase chain reaction (PCR). The PCR test was the Probetec DTB assay (Becton Dickinson), and the gene sequences targeted were IS6110 and 16S rRNA. His Mantoux test measured 25 mm and chest X-ray was clear. Full blood count revealed lymphocytosis, and other systemic investigations including HIV and syphilis were negative. The working diagnosis was that of a left eye panuveitis with tuberculous chorioretinitis, and he was started on ATT (6 months course of oral rifampicin, isoniazid and ethambutol) by the infectious disease specialist. He was subsequently started on oral prednisolone 40 mg a week later. Fundus fluorescein angiogram (Fig. 2a–c) revealed non-perfusion peripheral to the choroidal lesion representing a branch retinal vein occlusion, and he underwent a sectoral panretinal photocoagulation. In the third month of treatment, the patient was noted to have clinical deterioration with decrease in visual acuity to hand movement and progression of the chorioretinal lesion to the macula (Fig. 3). He underwent a repeat vitreous tap for which mycobacterial DNA PCR was now negative and received a dose of intravitreal amikacin 0.4 mg/0.1 ml. The patient was continued on systemic oral ATT and steroids, and the lesion slowly resolved, becoming smaller in size and developing fibrosis and later scarring. The patient’s final visual acuity at last follow-up was 6/120. The patient has given consent for the report to be published.Fig. 1


Paradoxical worsening of tuberculous chorioretinitis in a Chinese gentleman.

Siantar RG, Ho SL, Agrawal R - J Ophthalmic Inflamm Infect (2015)

a, b Fundus photos of left eye showing vitritis, vasculitis and chorioretinitis superior to the macula
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4496418&req=5

Fig1: a, b Fundus photos of left eye showing vitritis, vasculitis and chorioretinitis superior to the macula
Mentions: A 50-year-old man with past medical history of diabetes mellitus presented with 1 week history of left eye blurring of vision and mild discomfort. His Snellen visual acuity was 6/7.5 in the right eye and 6/15 in the left eye. Anterior segment examination revealed signs of uveitis with multiple keratic precipitates, anterior chamber cells 1+ and retrolental cells 2+. Fundus examination showed significant vitritis, vasculitis and a well defined yellowish-white chorioretinal lesion superior to the macula (Fig. 1a, b). Anterior and posterior segment examination of the right eye was normal. He underwent a vitreous tap which identified mycobacterial DNA via polymerase chain reaction (PCR). The PCR test was the Probetec DTB assay (Becton Dickinson), and the gene sequences targeted were IS6110 and 16S rRNA. His Mantoux test measured 25 mm and chest X-ray was clear. Full blood count revealed lymphocytosis, and other systemic investigations including HIV and syphilis were negative. The working diagnosis was that of a left eye panuveitis with tuberculous chorioretinitis, and he was started on ATT (6 months course of oral rifampicin, isoniazid and ethambutol) by the infectious disease specialist. He was subsequently started on oral prednisolone 40 mg a week later. Fundus fluorescein angiogram (Fig. 2a–c) revealed non-perfusion peripheral to the choroidal lesion representing a branch retinal vein occlusion, and he underwent a sectoral panretinal photocoagulation. In the third month of treatment, the patient was noted to have clinical deterioration with decrease in visual acuity to hand movement and progression of the chorioretinal lesion to the macula (Fig. 3). He underwent a repeat vitreous tap for which mycobacterial DNA PCR was now negative and received a dose of intravitreal amikacin 0.4 mg/0.1 ml. The patient was continued on systemic oral ATT and steroids, and the lesion slowly resolved, becoming smaller in size and developing fibrosis and later scarring. The patient’s final visual acuity at last follow-up was 6/120. The patient has given consent for the report to be published.Fig. 1

Bottom Line: However, he developed paradoxical worsening 2 months after initiation of therapy.He was continued on ATT, oral steroids and intravitreal amikacin with resolution of the chorioretinal lesion subsequently.Clinicians should strongly consider starting oral steroids concurrently with ATT when managing ocular tuberculosis.

View Article: PubMed Central - PubMed

Affiliation: Department of Ophthalmology, Tan Tock Seng Hospital, Singapore, 308433 Singapore.

ABSTRACT
We report a case of paradoxical worsening of tuberculous chorioretinitis after initiation of anti-tuberculous therapy (ATT). The patient had left panuveitis with tuberculous chorioretinitis and was started on systemic ATT and oral steroids a week later. However, he developed paradoxical worsening 2 months after initiation of therapy. He was continued on ATT, oral steroids and intravitreal amikacin with resolution of the chorioretinal lesion subsequently. Ocular tuberculosis often poses a diagnostic challenge, and clinicians should be aware of the possibility of paradoxical worsening despite appropriate ATT. Clinicians should strongly consider starting oral steroids concurrently with ATT when managing ocular tuberculosis.

No MeSH data available.


Related in: MedlinePlus