Tuberculosis: A Cunning Disease Presenting with Endopericarditis- Associated Bilateral Uveitis

Abstract

Mycobacterium tuberculosis can spread through the entire body but rarely involves the eye. We report a patient with endophthalmitis in one eye and simultaneous retinal vasculitis in the fellow eye. Systemic work-up suggested infective endopericarditis. Polymerase chain reaction analyses of the vitreous and pericardial fluid were positive for M. tuberculosis. We initiated a four-drug antituberculous treatment regimen (isoniazid, ethambutol, pyrazinamide, and rifampin). After two weeks, we discontinued all the medications due to drug-induced hepatitis. We restarted isoniazid and rifampin, but hepatitis recurred. Finally, we chose isoniazid/ethambutol combination for 18 months, and also administered short-term systemic corticosteroid. His vision improved considerably with no recurrence of hepatitis or tuberculosis for 3 years after completion of treatment. Ocular tuberculosis can masquerade as other causes of intraocular inflammation, and a medical team consisting of an ophthalmologist and an infectious disease specialist might be needed for the diagnosis and management.

<p>Endogenous Tuberculous Endophthalmitis and Panophthalmitis: A Systematic Review of Case Reports and Case Series</p>

“…Those included: CNS, abdominal and peritoneal, pericardial and adrenal. 19,21,27,28,31,37,53 Treatment regimens varied from case-to-case and included medications like rifampin, isoniazid, pyrazinamide and ethambutol, among others. The reported mortality in this series was low (1 case) but this could be due to under-reporting as follow-up duration varied significantly from study to study.…”

“…However, in 4/34 cases (12%), the contralateral eye was affected to a lesser degree (eg, chorioretinal lesion) and/or was not diagnosed as "endophthalmitis" or "panophthalmitis" by the original authors, thereby not meeting our eligibility criteria and not included in the analysis. 23,[25][26][27] There were no cases of bilateral TB endophthalmitis or panophthalmitis. Table 5 summarizes the clinical characteristics and working diagnoses on presentation.…”

“…23,34 Among the 3 other patients with contralateral ocular findings, endogenous endophthalmitis of unknown etiology was suspected in 2 cases without a specific suspicion for TB. 25,27 The last case, published by Sengupta et al, did not report a working diagnosis. 26 Treatments and Investigations Prior to TB Diagnosis Table 6 summarizes the clinical course, interventions and outcomes.…”

“…There was 1 case of TB adrenalitis and 1 case of TB pericarditis. 27,37 All patients were started on antituberculous treatment (ATT). Treatment regimens were variable and medications included rifampin, isoniazid, pyrazinamide and ethambutol, among others.…”

“…The visual acuity improvement from 20/630 to 20/32 was maintained for up to 3 years. 27 Microbiologic Studies Table 8 summarizes the best reported method of diagnosis and microbiologic findings. A TB etiology was confirmed on histopathologic specimen (HPS) after removal of the eye in 32/44 cases (72.7%).…”