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| BRIEF REPORT |
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| Year : 2006 | Volume
: 54
| Issue : 4 | Page : 273-275 |
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Fundus fluorescein angiography of choroidal tubercles: Case reports and review of literature
Salil Mehta
Lilavati Hospital and Research Centre, Mumbai, India
Correspondence Address:
Salil Mehta
202, Laxmi Villa, M.G. Road, Kandivali (W), Mumbai - 400 065
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0301-4738.27956
The aim of this communication was to report the fundus fluorescein angiography findings in three patients with choroidal tubercles. In all cases, there was a marked peritubercular inflammation. The tubercles themselves showed an initial hypofluorescence or minimal hyperfluorescence that increased in the late phases.
Clinicians need to be familiar with these new findings as they may help in the diagnosis of ocular tuberculosis.
Keywords: Choroid, fundus fluorescein angiography, tubercle
How to cite this article:
Mehta S. Fundus fluorescein angiography of choroidal tubercles: Case reports and review of literature. Indian J Ophthalmol 2006;54:273-5 |
Choroidal tubercles are seen in 1.4%[1] to 60%[2] of patients with different forms of tuberculosis. Histopathologically they represent caseating granulomas characterized by stromal destruction, swelling of the adjacent choroid and infiltration with round cells, epithelioid cells and giant cells.[3] Tubercle bacilli have been found within choroidal tubercles. They vary in size from 1/8th to several disc diameters (DD) with smaller-sized tubercles probably being commoner than the larger-sized tuberculomas. The literature regarding the angiographic features of the smaller and medium-sized lesions is limited. Laghmari and associates commented on the angiographic features of the tubercles in an 11-year-old with miliary tuberculosis and phlyctenular keratoconjunctivitis. They noted an early hypofluorescence and late moderate hyperfluorescence.[4] Campinchi-Tardy et al. described similar findings in three immunocompromised (HIV positive) patients with tubercles.[5] In contrast, angiographic studies of the larger-sized tuberculomas document findings that significantly differ from those described for the smaller tubercles. Cangemi[6] and Jabbour[7] have reported 2-3 and 4 DD in size lesions and have noted an early hyperfluorescence within the lesion that increases in intensity and size over the subsequent phases as dye leaks into the surrounding serous detachment and late leakage from the lesion along with reduction of this hyperfluorescence after treatment.
We report the clinical and angiographic features of three adult patients with small to medium-sized choroidal tubercles.
| Case 1 | |  |
A 48-year-old HIV negative female presented with a ten-day history of unsteadiness of gait, marked difficulty in walking and severe headache with vomiting.
A neurological examination suggested a cerebellar lesion, which was confirmed on magnetic resonance imaging. Multiple hyperintense ring-shaped lesions with perilesional edema were seen in the occipital lobe and the cerebellum and these lesions enhanced postcontrast, suggestive of tuberculous granulomas.
Her visual acuity was 20/20 in both eyes and her anterior segments were normal. Fundus examination of the left eye revealed two cream-colored ½ DD-sized choroidal lesions with an overlying and surrounding retinal edema [Figure - 1]a. The picture was consistent with choroidal tubercles. Fundus fluorescein angiography (FFA) showed a marked hyperfluorescence surrounding the tubercles in the early phases [Figure - 1]b, which increased in size and intensity over the mid and late phases. The tubercle showed an early hypofluorescence with the appearance of dye within the tubercle only in the mid-phase. The intralesional hyperfluorescence increased gradually over the mid and late phases until the appearance of a homogenous hyperfluorescence involving the tubercle and the surrounding tissues in the transit phases [Figure - 1]c. Some degree of late leakage was also seen. Two distinct zones were identified: an outer zone that is hyperfluorescent over all the phases and appears to be located in the surrounding (peritubercular) tissues and an inner initial hypofluorescent/late hyperfluorescent zone that corresponds to the tubercle. In the early phases, this may give rise to a "ring of fire" appearance. There were no abnormal fundus findings in the right eye.
She improved rapidly with marked reduction of her systemic symptoms and healing of the tubercle over the next week following antitubercular and systemic corticosteroid therapy.
| Case 2 | | |
A 51-year-old male presented with a five-day history of fever with chills. A chest X-ray showed a diffuse miliary shadowing suggestive of miliary tuberculosis and this was confirmed on computed chest tomography, which additionally showed the presence of a mediastinal (pretracheal and precarinal) lymphadenopathy. His visual acuity was 20/20 in both eyes and anterior segment examination showed no abnormality. Dilated fundus examination of the right eye showed a tubercle (½ DD in size) along the superotemporal arcade with indistinct borders and surrounding retinal edema. FFA showed an area of hypofluorescence corresponding to the tubercle surrounded by a hyperfluorescent zone in the early and mid phases. The entire lesion gradually turned hyperfluorescent in the late phases with leakage of dye into the surrounding tissues. There was a marked reduction of his fever and systemic symptoms with healing of the tubercle over the next few months on a regimen of antituberculous drugs and systemic corticosteroids.
| Case 3 | | |
A 26-year-old female presented for a routine examination. She had been diagnosed with miliary tuberculosis one month earlier based on suggestive chest X-rays and a computed tomogram (CT scan). Her visual acuity was 20/20 in both eyes and anterior segment examination showed no abnormality. Dilated fundus examination showed multiple tubercles measuring from ½ to 1 DD in size scattered throughout the posterior poles of both fundi. There was an area of retinal edema surrounding the tubercles. An FFA showed an early hypofluorescence corresponding to the tubercle surrounded by a hyperfluorescent zone in the early and mid phases. The entire lesion gradually turned hyperfluorescent in the late phases with leakage of dye into the surrounding tissues. Healing of the tubercles continued over the next few months on a regimen of antituberculous drugs and systemic corticosteroids.
| Discussion | | |
The tubercles (varying from ½ DD to 1 DD in size) were largely localized to the posterior pole and were invariably associated with surrounding retinal edema suggesting active inflammation. The subsequent angiograms shared certain common features. There was an initial hypofluorescence within the tubercle followed by a hyperfluorescence. There was a consistent appearance of significant peritubercular fluorescence from the early phases that increased in intensity in the late phases with an increase in the size of the lesion in the late phases.
The presence of antigen within the choroid leads to the activation of an immune reaction that includes the generation and release of numerous types of complement, chemokines and cytokines including IL-1, TNF-a, IL-6 and interferon-g. The cumulative effect is to mediate a marked local inflammation with a resultant increase in vascular permeability, cellular infiltration and the production of tissue-damaging proteases.[8] The effect of these mediators on the small vessels in the surrounding tissues may be responsible for the observed peritubercular fluorescein leak. This may clinically correlate to the surrounding retinal edema and suggests that the inflammatory activity may extend well beyond the visible tubercle. The initial hypofluorescence of the tubercle is due to an initial masking effect of the lesion with a gradual leakage of dye into the lesion that turns it hyperfluorescent in the late phases. It is possible that retinal pigment epithelium pathology may also contribute to the clinical and angiographic picture. A simultaneous retinal pigment epithelitis, due to its proximity to the choroidal lesion, may account in part for the observed peritubercular hyperfluorescence. The central portion of the lesion would remain hypofluorescent due to tubercle-induced blockage and would gradually turn hyperfluorescent.
The cases we report significantly differ from earlier reports. Peritubercular hyperfluorescence has not been reported to date and these angiographic findings also differ from those reported in patients with the larger-sized tuberculomas. One possibility to explain this difference is larger size of lesions (2 to 4 DD) described in those reports versus the smaller size of the lesions (½ to 1 DD) we studied and the possible histopathological differences.
| Conclusion | | |
Choroidal tubercles tend to be hypofluorescent in the early phases and hyperfluorescent in the late phases with an accompanying peritubercular hyperfluorescence that may represent focal infection and inflammation.
| References | | |
| 1. | Biswas J, Badrinath SS. Ocular morbidity in patients with active systemic tuberculosis. Int Ophthalmol 1995-1996;19:293-8.  |
| 2. | Illingworth RS, Lorber J. Tubercles of the choroid. Arch Dis Child 1956;31:467-9. [ PUBMED] |
| 3. | Helm CJ, Holland GN. Ocular tuberculosis. Surv Ophthalmol 1993;38:229-56. [ PUBMED] [ FULLTEXT] |
| 4. | Laghmari A, Boutimzine N, Elmoussaif H, Benjelloun A, Essakalli NH, Benabdallah N, et al . Bouchut's tubercles. Clinical and angiographic study, apropos of a case. J Fr Ophtalmol 1997;20:383-6. |
| 5. | Campinchi-Tardy F, Darwiche A, Bergmann JF, Chedin P, Nemeth J, Campinchi R, et al . Bouchut tubercles and AIDS. Apropos of 3 cases. J Fr Ophtalmol 1994;17:548-54. |
| 6. | Cangemi FE, Friedman AH, Josephberg R. Tuberculoma of the choroid. Ophthalmol 1980;87:252-8. |
| 7. | Jabbour NM, Faris B, Trempe CL. A case of pulmonary tuberculosis presenting with choroidal tuberculoma. Ophthalmology 1985;92:834-7. |
| 8. | Magone TM, Whitcup SM. Mechanisms of Intraocular Inflammation. In : Streilin JW (editor). Immune response and the eye. Karger: Basel; p. 90-119. |
[Figure - 1]
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