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| CASE REPORT |
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| Year : 2021 | Volume
: 29
| Issue : 1 | Page : 58-61 |
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Choroidal Tuberculoma Presenting with Exudative Retinal Detachment in a Young Male: A Case Report
Yewande O Babalola1, Soumyava Basu2
1 Department of Ophthalmology, University College Hospital, Ibadan, Nigeria; LV Prasad Eye Institute, Mithu Tulsi Chanri Campus, Bhubaneshwar, India
2 Department of Ophthalmology, University College Hospital, Ibadan, Nigeria
| Date of Submission | 12-May-2020 |
| Date of Decision | 15-Aug-2020 |
| Date of Acceptance | 13-Oct-2020 |
| Date of Web Publication | 16-Jul-2021 |
Correspondence Address:
Dr. Yewande O Babalola
Department of Ophthalmology, University College Hospital, Ibadan, Nigeria
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/njo.njo_18_20
An 18-year-old male student presented with a 1 month history of poor vision in the right eye. Ocular examination revealed visual acuity of hand movement and 20/20 in the right and left eyes, respectively. Inflammatory cells were present in the anterior chamber of the right eye. Fundus examination revealed a right exudative retinal detachment with a tuberculoma in the superotemporal quadrant, whereas the left eye was normal. There was a positive history of contact with a relative with pulmonary tuberculosis. The patient was treated with a combination of antituberculous therapy and oral corticosteroids for 6 months following which the lesion resolved completely with full recovery of vision to 20/20 in the right eye.
Keywords: Choroidal tuberculoma, exudative retinal detachment, disc edema, fibrotic scar, chorioretinal atrophy, pulmonary tuberculosis, antituberculous therapy
How to cite this article:
Babalola YO, Basu S. Choroidal Tuberculoma Presenting with Exudative Retinal Detachment in a Young Male: A Case Report. Niger J Ophthalmol 2021;29:58-61 |
| Introduction | |  |
Choroidal tuberculoma is a rare ocular manifestation of tuberculosis. Granulomas that are the hallmarks of tuberculosis (TB) arise in the choroid through hematogenous seeding of Mycobacterium TB from the lungs.[1] Choroidal tuberculomas typically appear as one or more yellowish-white mass lesions of variable size, involving any part of the fundus. Occasionally, they may be associated with exudative retinal detachment and involve the optic nerve head.[2],[3],[4] Systemic foci of TB that may be pulmonary, extrapulmonary, or disseminated may coexist with choroidal tuberculomas.[5],[6],[7] More commonly, choroidal tuberculoma may occur in isolation in the absence of systemic disease.[4],[8]
| Case Report | | |
An 18-year-old male student presented to the retina outpatient department with a 1 month history of poor vision in the right eye for both distance and near. The visual deterioration was gradual and there was no antecedent history of ocular trauma. There was no preceding history of flashes of light, floaters, redness, or photophobia.
On ocular examination, the best-corrected visual acuity was hand movement with accurate light projection and 20/20 in the right and left eyes, respectively. Slit-lamp examination of the right eye revealed grade 1 inflammatory cells in the anterior chamber and anterior vitreous face. Indirect ophthalmoscopy revealed a sub-retinal yellow-white mass lesion approximately 6 mm × 7.5 mm in size in the superotemporal quadrant associated with a bullous, exudative retinal detachment extending into the inferior quadrants obliterating the view of the optic disc [Figure 1]. No retinal breaks or holes were present. The anterior segment of the left eye and the left fundus was unremarkable. Intraocular pressure measured by Goldman applanation tonometry was 06 and 10 mmHg, respectively, in the right and left eyes. In view of the clinical findings, the differential diagnoses considered were choroidal tuberculoma, amelanotic choroidal melanoma, and choroidal metastasis. | Figure 1 Shows the right fundus at first presentation with an elevated lesion (blue arrow) representing the area of choroidal granuloma and a haemorrhage in the superotemporal quadrant with bullous exudative retinal detachment
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B-scan ultrasonography of the left eye showed a dome-shaped mass with moderate homogeneous echogenicity of the lesion with no evidence of calcification [Figure 4]. Based on the clinical and ultrasonographic findings, we made a provisional diagnosis of inflammatory choroidal granuloma, most likely tuberculoma with exudative retinal detachment in the right eye. | Figure 4 Views of the B-scan ultrasonography of the right eye with a large dome –shaped, echogenic, homogenous and echogenic lesion, subretinal fluid, low reflective membranes in the vitreous cavity and retinochoroidal thickening
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Laboratory investigations revealed an elevated erythrocyte sedimentation rate of 76 mm/hr, whereas the chest X-ray showed left pleural effusion with thickening of the pleura. No lesion was seen in the lung fields. Tuberculin skin test and Quantiferon TB Gold both tested positive. Tests for HIV-1 and 2 were nonreactive.
On inquiry, the patient gave a positive history of contact with a cousin with a chronic cough who was on treatment for TB prior to presentation. Our patient was commenced on intensive treatment phase with four-drug anti-TB therapy (ATT) comprising of rifampicin 600 mg, isoniazid 450 mg, pyrazinamide 1.5 g, and ethambutol 800 mg once daily for a period of 2 months then rifampicin 600 mg and isoniazid 450 mg for the next 4 months in the continuation treatment phase. One month after starting ATT, the patient was commenced on oral prednisolone 50 mg/day that was tapered off over a period of 3 months. He was followed up by the physicians.
A rapid regression of the choroidal tuberculoma and reduced bullousity of the detachment was observed 2 weeks after the commencement of ATT with progressive improvement in the visual acuity in the right eye. The optic nerve head was now visible with a blurring of the disc margins in keeping with optic disc edema [Figure 2]. Subretinal fluid resolution was gradual with eventual total absorption on completion of antituberculous therapy. | Figure 2 The right montage fundus picture two months after commencement of anti-tuberculous therapy showing the choroidal granuloma in the superotemporal quadrant (yellow arrow), blurring and hyperaemia of the disc margins indicating disc oedema (green arrow) and also minimal subretinal fluid superiorly
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At the last follow-up visit, best-corrected visual acuity was 20/20 in both eyes with no activity in the anterior segment, total resolution of the retinal detachment, and fibrotic scar with chorioretinal atrophy at the site of the tuberculoma [Figure 3]. | Figure 3 The right montage fundus picture after completion of anti-tuberculous therapy showing chorioretinal atrophy and pigmentation in the superotemporal quadrant with a healed, wedge-shaped, fibrotic chorioretinal scar (purple arrow) at the area of the granuloma with total resolution of the pre-existing exudative retinal detachment
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| Discussion | | |
Our index patient presented with poor vision in the right eye and clinical findings of a choroidal mass suggestive of a tuberculoma with an exudative retinal detachment. Laboratory investigations were confirmatory for TB. He responded well to treatment with systemic antituberculous and steroid therapy with a total resolution of the exudative detachment and good visual outcome.
Choroidal tuberculomas are usually unilateral, solitary yellowish or grayish-white lesions with indefinite borders located in the posterior pole. These tubercles may be multiple and may vary in presentation with features such as associated hemorrhage, striae, or exudative retinal detachment, although retinal vessels overlying the choroidal lesions may appear normal.[1],[8],[9] Close differentials of choroidal tuberculomas are choroidal tumors that have similar clinical features and mimic these tuberculomas in their presentation. They may also occur with exudative retinal detachments.[10],[11] On B-scan ultrasonography, choroidal tuberculomas are seen as dome-shaped, concave, or diffuse lesions with moderate echoic heterogeneity as seen in our patient, whereas malignant melanomas show a mushroom or lobulated shape and may be hyperechoic with or without acoustic hollowing.[12]
The diagnosis of choroidal tuberculoma is usually a presumptive one based on relevant clinical and laboratory findings after the exclusion of similar granulomatous conditions. Histopathologic confirmation, which is needed for definite diagnosis of TB is usually not possible in choroidal tuberculoma. Experimental studies in animal eyes infected with Mycobacterium TB bacilli revealed creamy yellow lesions and signs in keeping with granulomatous inflammation showing prominent thickening of the choroid, central necrosis, decreased choroidal vasculature, retinal hemorrhages, and vascular endothelial staining in the retinal pigment epithelium that were all absent in age-matched controls. Although acid-fast bacilli were absent in the choroidal lesions, it is postulated that this may be due to the small amount of acid-fast bacilli inoculated into the animal eyes.[13] The mechanism of exudative retinal detachment in ocular TB is still not fully understood.
In a systematic review of literature, 32 eyes from 26 studies and 28 patients relating to ocular TB presenting with exudative retinal detachment, choroidal tuberculoma was the most common (53.1%) clinical feature followed by optic nerve head edema (18.8%).[4] These two top characteristic clinical signs were elicited in our index patient as seen in [Figure 1] and [Figure 3].
Song et al.[4] reported a case of a patient with TB presenting with unilateral exudative detachment and choroidal tubercles. There were no pulmonary signs in their patient but a cystic lesion was present at L1 vertebrae. Lesions resolved with antituberculous therapy and systemic steroids. A case of choroidal tuberculoma and exudative retinal detachment in a patient with severe pulmonary TB and left parietal tuberculoma confirmed by Mantoux and gamma quantiferon gold tests has also been documented.[6]
The mainstay of treatment for all variants of ocular TB with the inclusion of choroidal tuberculoma is the treatment of the tuberculous infection. The use of antituberculous therapy and corticosteroids has been found to give good outcomes.[4] Although uncommon, choroidal tuberculoma coexisting with exudative retinal detachment with resolution of the lesions on treatment with antituberculous drugs and corticosteroid therapy has been reported in the literature.[4],[5],[6]
Other modalities of treatment that have been tried include the use of antivascular endothelial growth factor agents. It is thought that persistence of the granuloma despite antituberculous therapy may point toward enhanced vascularity of the lesion that responds favorably to the use of intravitreal antivascular endothelial growth factor.[14],[15] Regression of choroidal tuberculoma has also been documented in isolated cases treated with ranibizumab monotherapy.[16]
| Conclusion | | |
Choroidal tuberculoma is a rare ocular manifestation of TB and may be associated with exudative retinal detachment. A high index of suspicion, detailed history, and clinical examination with relevant laboratory workup are essential in making a definitive diagnosis. Treatment with antituberculous drugs usually results in complete resolution of the lesion.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Tripathy K, Chawla R. Choroidal tuberculoma. Natl Med J India 2016;29:106.  [ PUBMED] [Full text] |
| 2. | Gupta A, Gupta V. Tubercular posterior uveitis. Int Ophthalmol Clin 2005;45:71-88. |
| 3. | Invernizzi A, Franzetti F, Viola F, Meroni L, Staurenghi G. OOptic nerve head tuberculous granuloma successfully treated with intravitreal anti-VEGF injections in addition to systemic therapy. Eur J Ophthalmol 2015;25:270-2. |
| 4. | Song JH, Koreishi AF, Goldstein DA. Tuberculous uveitis presenting with a bullous exudative retinal detachment: a case report and systematic literature review. Ocul Immunol Inflamm 2019;27:998-1009. |
| 5. | Jabbour NM, Faris B, Trempe CL. A case of pulmonary tuberculosis presenting with choroidal tuberculoma. Ophthalmology 1985;92:834-7. |
| 6. | Agarwal M, Maitray A, Khetan V. Unusual presentation of choroidal tuberculoma. Ophthalmology 2017;124:708. |
| 7. | Sharma PM, Singh RP, Kumar A, Prakash G, Mathur MB, Malik P. Choroidal tuberculoma in miliary tuberculosis. Retina 2003;23:101-4. |
| 8. | Levecq LJ, Potter P. Solitary choroidal tuberculoma in an immunocompetent patient. Arch Ophthalmol 2005;123:864-6. |
| 9. | Cangemi FE, Friedman AH, Josephberg R. Tuberculoma of the choroid. Ophthalmology 1980;87:252-6. |
| 10. | Gupta V, Gupta A, Rao NA. Intraocular tuberculosis − an update. Surv Ophthalmol 2007;52:561-87. |
| 11. | Papastefanou VP, Cohen VM, Tuberculoma of the choroid masquerading as a choroidal melanoma. Eye 2011;25:1519-20. |
| 12. | Mithal KN, Thakar HH, Tyagi MA, Bharwada RM, Billore PO. Role of echography in diagnostic dilemma in choroidal masses. Indian J Ophthalmol 2014;62:167-70. [ PUBMED] [Full text] |
| 13. | Thayil SM, Albini TA, Nazari H et al. Local ischemia and increased expression of vascular endothelial growth factor following ocular dissemination of Mycobacterium tuberculosis. PLoS One 2011;6:e28383. |
| 14. | Ruiz-Cruz M, Espinosa E, Romero K, Reyes-Teran G. Bevacizumab reverts serous retinal detachment caused by tuberculous-associated immune reconstitution inflammatory syndrome. AIDS 2011;25:1241-3. |
| 15. | Babu K, Murthy PR, Murthy KR. Intravitreal bevacizumab as an adjunct in a patient with presumed vascularised choroidal tubercular granuloma. Eye 2010;24:397-9. |
| 16. | Jain S, Agarwal A, Gupta V. Resolution of large choroidal tuberculoma following monotherapy with intravitreal ranibizumab. Ocul Immunol Inflamm 2019;15:1-4. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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