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   Table of Contents      
CASE REPORT
Year : 1983  |  Volume : 31  |  Issue : 2  |  Page : 89-92

Conjunctival tuberculosis of endogenous origin associated with miliary tuberculosis


Department of Ophthalmology, Jawaharlal Institute of Post-Graduate Medical Education & Research, Pondicherry, India

Correspondence Address:
P A Lamba
Professor of Ophthalmology, Jawaharlal Institute of Post-Graduate Medical Education & Research, Pondicherry 605 006
India
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Source of Support: None, Conflict of Interest: None


PMID: 6662577

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How to cite this article:
Lamba P A, Srinivasan R. Conjunctival tuberculosis of endogenous origin associated with miliary tuberculosis. Indian J Ophthalmol 1983;31:89-92

How to cite this URL:
Lamba P A, Srinivasan R. Conjunctival tuberculosis of endogenous origin associated with miliary tuberculosis. Indian J Ophthalmol [serial online] 1983 [cited 2020 Oct 31];31:89-92. Available from: https://www.ijo.in/text.asp?1983/31/2/89/27448

Ocular tuberculosis is comparatively rare in patients with frank pulmonary tuberculosis The incidence of manifest ocular involvement[1] in TB Sanatoria patients is less than 0.1%. It is usually seen in apparently healthy indivi­duals who show evidence of an old or healed focus only. The mode of ocular involvement in tuberculosis may be direct organismal in­fection following a tuberculous bacillaemia or an allergic (hypersensitivity) reaction to tubercular protein. Primary ocular tuber­culosis (exogenous, air borne infection) is uncommon.

In India, although systemic tuberculosis is rampant ocular involvement is a rarity. The most common ocular disease in tuberculous patients was phlycten[2]. To the best of our knowledge a bacteriologically proved case of ocular tuberculosis has not yet been reported from India. The case being reported here had both epibulbar and intra-ocular lesions.


  Case report Top


A young lady, aged 30 years presented in the Ophthalmology Department of JIPMER Hospital with the complaint of right sided headache, pain, watering and redness in the right eye for one month. It was associated with rapid deterioration of vision over the same period. She also noticed a gradually increasing reddish yellow mass in the medial aspect of the right eye for the same duration. For the last 6 weeks the patient also complai­ned of intermittent moderate grade fever with weight loss. There was no history of cough. The patient had delivered a full term baby 15 days prior to the onset of her ocular complaints. The antenatal period was normal.

General examination revealed an ill-look­ing pale, thin built young lady with low grade pyrexia (100`F) without any lymphadeno­pathy. Systemic examination revealed scatte red bilateral pulmonary rales with mild hepato-splenomegaly.

Ocular examination-There was a right divergent squint 15 with limitation of addu­ction of the right eye. The right eye showed conjunctival and ciliary congestion, and two reddish yellow, soft, non tender nodules were seen on the medial aspect of the right bulbar conjunctiva about 8 mm from the limbus [Figure - 1]a. The surface of the lesion appeared necrotic. Examination of the anterior segment revealed presence of aqueous flare, no keratic precipitates, normal anterior chamber depth, mid-dilated irregular fixed pupil with extensive posterior synechia, diffuse muddiness of the iris. There was an extensive exudation into the vitreous giving a yellow reflex in the in the pupillary area [Figure - 1]B. No view of the fundus was Hemogram showed Hb g°,,, TLC 7000/ cmm. Neutrophil 65%, Dymphocytes 30%. ESR 60 mm (Westergren). Chest X-ray showed pattern of active miliary mottling of both lung fields [Figure - 2]A. Mantoux test was negative. A gastric lavage for acid fast bacillus revealed mycobacterium tuberculosis. Scraping from the centre of both epibulbar lesions were positive for AFB on Ziehl Neelsen stain [Figure - 3]. Culture from the same lesion yielded heavy growth of mycobacterium tuberculosis in three weeks.

The patient was treated with Tab. Isoniazid 300 mg and Inj. streptomycin sulphate 0.75 G daily. Tab. Ethambutol 500 mg. was added after 2 weeks. A low dose of steroids (5 mg 6 hourly) was also given on the advice of the physician.

After one month of treatment the general condition of the patient improved with a weight gain of 5 kg. ESR had fallen to 15 mm (Westergren). A repeat Roentgenogram showed some clearing of the lung lesions [Figure - 2]B. The conjunctival nodules became flat in 3 weeks and the right eye showed signs of quietening. The yellow fundal reflex appeared denser and slit lamp examination revealed a fibrovascular mass in the vitreous. Fundus view, however remained obscure. The lesions in the left eye remained unaltered.


  Discussion Top


The case reported here has some unique and interesting features in that the patient had epibulbar and intraocular lesions due to mycobacterium tuberculosis. Proved cases of tuberculosis of conjunctiva are quite rare and only a few scattered reports are available in the litelature[3],[4],[5]. Conjunctival tubercu­losis secondary to systemic involvement is of exceedingly rare occurrence since conjunetival involvement if at all, is most commonly asso­ciated with direct inoculation of organisms into the conjunctiva or is by contigeuous spread[3],[4],[5],[6].

Conjunctival tuberculosis can assume different forms like ulcerative, nodular, polypoidal and hypertrophic capillary type depending upon the mechanism of infection and perhaps also on the state of immunity or allergy of the patient. The formation of sub­conjunctival tuberculoma is characterised by coagulative necrosis and caseation as toxic reaction to mycobacterium tuberculosis. This form of manifestation is uncommon and likely to be confused with necrotising scleritis. In the present case the diagnosis was confirmed by the demonstration and the culture of mycobacteria by standard Ziehl Neelsen procedure. Conjunctival lesions in this patient probably represented an endogenous infection during the stage of tuberculous bacillaemia.

The most striking characteristic of ocular tuberculosis is the marked pleomorphism of the lesions. The intraocular involvement in miliary tuberculosis is usually in the form of miliary tubercles or tuberculoma of the choroid. Such a diffuse proliferative reaction as in this case is rare[7]. In our case the intraocular involvement differed in the two eyes. In the left eye were seen typical miliary choroidal lesions with minimal reaction while in the right eye there was an endophthalmitis like picture with severe anterior segment reaction. The lesion probably started as a conglomerate tubercle in the posterior seg­ment resulting from the break down of a solitary tubercle followed by an extension of the inflammation with necrosis into the surrounding tissues. Later a diffuse prolifera­tive reaction with secondary iritis, caseation and necrosis obscured all view of the fundus.

An eye lost due to intraocular inflamma­tion (Acute tuberculous endophthalmitis) without any clinical evidence of pulmonary tuberculosis was reported by Theobald[8]. Tile histopathology of the enucleated globe was later reviewed and confirmed to be due to mycobacterium tuberculosis. The general condition of the patient unproved favourably with the anti-tubercular chemotherapy though the response was slow. The pleomorphic picture produced by mycobacterium tuber­culous in the conjunctiva and the chorio­retinal lesions in the two eyes is well exam­plified in this case.


  Summary Top


A young Indian lady had bulbar conjun­ctiva) nodules with central necrotic area in right eye. It was proved to be caused by myco-bacterium tuberculosis on smear and culture examinations. She was found to have active pulmonary miliary tuberculosis also. The case was unusual in that the endogenous infection caused miliary tubercles in the left fundus but produced a diffuse proliferative reaction simulating endophthalmitis in the right eye. The patient showed definite signs of improvement with anti-tubercular chemotherapy.

 
  References Top

1.
Sorsby, A.. 1963, : Modern Ophthalmology. Vol. 2, P. 117 London, Butter Worths.  Back to cited text no. 1
    
2.
Srinivasa Rao P.N. and Bhat S.K, 1967, Active systemic lesions in cases of suspected ocular tuberculo­sis. J. All Ind. Ophthalmol. Soc. 15 : 175.  Back to cited text no. 2
    
3.
Bruce, G.M. and Locatcher-Khorazo, D, 1947, Arch. Ophthalmol. 37 : 375.  Back to cited text no. 3
    
4.
Woods, A.C. 1954, Pathogenesis and treatment of ocular tuberculosis Arch. Ophthalmol. 52: 174.   Back to cited text no. 4
    
5.
Anhalt, E.F, Zavell, S. Chang, G. and Byron, H.M. 1960, Am. .J Ophthalmol. 50 : 265-269.  Back to cited text no. 5
    
6.
Goldfrab AA.. Seltzer 1963 : Amer J Dis. Child 72:211.  Back to cited text no. 6
    
7.
Liesegang, T.J. and Cameron. J.D. 1980, Arch. Ophthalmol 98: 1764.  Back to cited text no. 7
    
8.
Dvorak-Theobald, G: 1958, Amer..1. Ophthal, 45 : 403  Back to cited text no. 8
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]



 

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