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PHOTO ESSAY
Year : 2020  |  Volume : 68  |  Issue : 4  |  Page : 639-640

A cute bilateral conjunctivitis with nasooral involvement: A rare manifestation of tuberculosis


1 Department of Ophthalmology, Fortis Hospital, Mulund, Mumbai, Maharashtra, India
2 Consultant Physician, Fortis Hospital, Mulund, Mumbai, Maharashtra, India
3 Cornea Service, Tej Kohli Cornea Institute, Kallam Anji Reddy Campus, LV Prasad Eye Institute, Hyderabad, Telangana, India

Date of Submission27-Mar-2019
Date of Acceptance10-Oct-2019
Date of Web Publication16-Mar-2020

Correspondence Address:
Dr. Suresh Palanisamy
Chief Ophthalmic Surgeon, Fortis Hospital, Mulund, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_566_19

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Keywords: Conjunctival tuberculosis, mediastinal mass, perilimbal nodules


How to cite this article:
Palanisamy S, Mathews AD, Murthy SI. A cute bilateral conjunctivitis with nasooral involvement: A rare manifestation of tuberculosis. Indian J Ophthalmol 2020;68:639-40

How to cite this URL:
Palanisamy S, Mathews AD, Murthy SI. A cute bilateral conjunctivitis with nasooral involvement: A rare manifestation of tuberculosis. Indian J Ophthalmol [serial online] 2020 [cited 2020 Apr 2];68:639-40. Available from: http://www.ijo.in/text.asp?2020/68/4/639/280689



Ocular tuberculosis (TB) is rare.[1] TB most commonly presents as uveitis and phlyctenular conjunctivitis. Conjunctival TB is a well-established clinical entity and may appear as an ulcerative lesion, military tubercle, hypertrophic granulation, lupus, or pedunculated mass.[2],[3] We report a case of acute nodular bilateral conjunctivitis associated with inflammation of the mouth and the nostril. However unlike phlycten, these nodules were multiple, bilateral, and associated with intense conjunctival congestion. Further evaluation of the patient revealed a mediastinal mass that later proved to be TB on biopsy pathology. This is a rare manifestation of conjunctival inflammation with stomatitis and vestibulitis in a case of mediastinal tuberculosis. To the best of our knowledge such presentation has never been reported.

A 16-year-old girl presented with complaints of redness, watery discharge, and moderate pain in both the eyes since 2 weeks with discomfort of the mouth and nose. She was treated with topical moxifloxacin and carboxymethyl cellulose eye drops with no improvement. Systemically, she complained of episodes of mild fever and loss of weight in the past few months.

Facial examination revealed bilateral red eyes [Figure 1] and [Figure 2], erythema of the left nostril with crusts and mild red lips with crusting [Figure 3]. The visual acuity was 6/6 in both eyes. Examination of showed intense conjunctival congestion with multiple, elevated, flat topped limbal nodules in both the eyes. The patient was referred to a dermatologist and ENT surgeon. Both the dermatologist and ENT surgeon made a diagnosis of nonspecific inflammation and advised medical management. High-resolution chest CT scan revealed confluent necrotic mediastinal nodes in the right paratrechial and subcarinal locations. [Figure 4] She underwent computed tomography-guided biopsy of the mediastinal mass. Histopathology revealed granulomatous inflammation with the presence of 20% acid fast bacilli. The culture grew Mycobacterium tuberculosis. The conjunctivitis resolved with topical prednisolone acetate 1% eye drops and systemic condition improved with oral anti-TB regime. There was no recurrence when followed up at 6 months.
Figure 1: Right eye (RE) conjunctival congestion with perilimbal nodules

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Figure 2: Left eye (LE) showing conjunctival congestion with large perilimbal nodules

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Figure 3: Erythema of the left nostril with crusts and mild red lips with crusting

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Figure 4: High-resolution CT chest showing mediastinal mass

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The causation of the conjunctival and oral mucosal inflammation is likely due to the systemic disease, as no other pathology could be found and also there were no recurrences after the treatment. We believe this presentation is likely to represent a hypersensitivity reaction to systemic TB and may share some similarity with the cases described as atypical SJS or Fuch's syndrome associated with mycoplasma pneumonitis[4],[5] possibly having similar pathophysiology. In countries like India where TB is rampant being aware of such unusual presentation helps in the earlier detection of systemic TB.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Biswas J, Badrinath SS. Ocular morbidity in patients with active systemic tuberculosis. Int Ophthalmol 1995;19:293-8.  Back to cited text no. 1
    
2.
Chaurasia S, Ramappa M, Murthy SI, Venmuganti GK, Fernandes M, Sharma S, et al. Chronic conjunctivitis due to Mycobacterium tuberculosis. Int Ophthalmol 2014;34:655-60.  Back to cited text no. 2
    
3.
Helm CJ, Holland GN. Ocular tuberculosis. Surv Ophthalmol 1993;38:229-56.  Back to cited text no. 3
    
4.
Latsch K, Girschick HJ, Abele-Horn M. Stevens-Johnson syndrome without skin lesions. J Med Microbiol 2008;56:1696-9.  Back to cited text no. 4
    
5.
McGouran DC, Petterson T, McLaren JM, Wolbinski MP. Mucositis, conjunctivitis but no rash -the “Atypical Stevens-Johnson syndrome”. Acute Med 2011;10:81-2.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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