Year : 1967 | Volume
: 15 | Issue : 5 | Page : 175--180
Active systemic lesions in cases of suspected ocular tuberculosis
PN Srinivasa Rao1, K Shankar Bhat2,
1 Department of Ophthalmology, Kasturba Medical College, Manipal, India
2 Department of General Medicine, Kasturba Medical College, Manipal, India
P N Srinivasa Rao
Department of Ophthalmology, Kasturba Medical College, Manipal
|How to cite this article:|
Srinivasa Rao P N, Bhat K S. Active systemic lesions in cases of suspected ocular tuberculosis.Indian J Ophthalmol 1967;15:175-180
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Srinivasa Rao P N, Bhat K S. Active systemic lesions in cases of suspected ocular tuberculosis. Indian J Ophthalmol [serial online] 1967 [cited 2021 Apr 10 ];15:175-180
Available from: https://www.ijo.in/text.asp?1967/15/5/175/38803
Tuberculosis can affect the eye in two ways:-(1) actual infection of the ocular tissue by the organism, (2) an allergy to tuberculous proteins. While it is conceded, that tuberculosis is an important and frequent cause of ocular diseases such as uveitis, the importance and frequency ascribed to it vary from clinic to clinic, according to various diagnostic criteria employed, the nutritional status of the region and the success of anti-tubercular measures. The problem is complicated due to several factors: (1) Inability to demonstrate bacilli in the available aqueous. (2) Lack of tissue for biopsy or culture. (3) The pleomorphic clinical symptomatology which may be simulated by a great variety of other infections. (4) Immunological tests such as Mantoux test have got little diagnostic value in an area where the test seems to be universally positive in the general public. Under the circumstances, the problem is reviewed here in reverse. Cases suspected of ocular tuberculous lesions were subjected to general medical survey by one of us (K.S.B.) to find out systemic active lesions if any.
Review of Literature
European investigators report a high incidence of systemic tuberculosis in patients with ocular tuberculosis. WERDENBERG (1938) reported that 60% of the ocular tuberculous patients at Davos showed calcified hylar nodes, 30% showed X-Ray evidences of old inactive infection in the lung fields, and the remaining 10% showed evidence of active systemic tuberculosis. WEGNER and ZINTZ (1951) reported severe pulmonary changes in 10% of 300 cases of frank ocular tuberculosis, and unmistakable tuberculous foci elsewhere in the body in 60%.
In an analysis of 306 patients with ocular tuberculosis LASCU GROSSU and NICULESCU (1956) found "antagonism" (severe ocular symptoms and slight or inactive pulmonary involvement) in 67% of the cases, parallism (severe ocular symptoms and severe active, pulmonary or systemic lesions) in 21 % and what they termed slight parallism in the remaining 12%.
For many years phlyctenular keratoconjunctivitis has been associated with tuberculosis. The positive dermal reaction is found in a percentage of cases varying from 60 to 100 with an average of 80%. The frequency with which clinical evidence of the presence of active tuberculosis, whether pulmonary or lymphatic can be obtained in phlyctenular subjects has varied widely with different observers. Thus Stalder (1926) as quoted by Duke Elder (1965) found lung lesions in 83% of the patients with phlyctenes in contrast to 6% in controls. SIWE (1935) diagnosed active pulmonary lesions in a considerable proportion of patients with phlyctenes depending on the age, varying from 75% in children under 4 years to 26°% o between 7 and 13. SORSBY (1942) and THYGESON (1951) found a relatively small percentage of active tuberculosis either in the lungs, lymphnodes, bones or joints (6%). But all observers are agreed that radiological evidence of past disease is very high. (72.2%, SORSBY-1942).
KONTAS K. A. (1958) found abnormalities of the fundus in 43 out of 318 patients (13%) with pulmonary tuberculosis.
PACYNSKA (1957) studied 500 patients with pulmonary tuberculosis and found only 2 cases of choroidal foci which can be considered definitely tuberculous.
The dominant role ascribed to tuberculosis in the etiology of uveitis has undergone considerable de-emphasis. In 1941, a report from the Wilmer Institute indicated tuberculosis to be the cause of 79% of all instances of uveitis. In 1944, this figure dropped to 52% and in 1953 to 22%. The present day concepts of the importance of tuberculous uveitis varies from a maximum of 75% to a minimum of only 10% (THEODORE and SCHLOSSMAN 1958).
THEODORE and SCHLOSSMAN (1958) concluded that the incidence of ocular tuberculosis is not proportional to the incidence of systemic disease. Ocular involvement rarely occurs in systemic tuberculosis unless there is miliary dissemination. In a study of 2000 Alaskan children, all of whom were affected with pulmonary or extra pulmonary tuberculosis, FRITZ, THYGESON and DURHAM (1951) failed to uncover a single instance of uveitis, tuberculous or otherwise.
The rarity of active ocular tuberculosis in sanatorium patients with active pulmonary tuberculosis is well known. AMSLER (1957) places this figure at less than 1%. In the Wilmer Institute series, active pulmonary lesions were only occasionally found in patients with ocular tuberculosis and in only approximately 507, were there inactive lesions in the lung fields or abnormal mediastinal changes attributable to tuberculosis.
THEODORE AND SCHLOSSMAN (1958) suggest that the lack of correlation of the eye complaints with systemic tuberculosis might indicate (1) that a long latent period occurs before the tubercle bacilli travel from the lung or any extra pulmonary source to the eye, (2) that the uvea is not an especially receptive site for, the tubercle bacilli and (3) that some other mechanism possibly allergic is responsible for uveal tuberculosis.
The clinical manifestations of ocular tuberculosis are protean and are too familiar for detailed descriptions. Any and every part of the eye can be involved in either or both the two ways mentioned above, viz. infection and allergy to tuberculous proteins.
The methods available for the diagnosis of ocular tuberculosis are unsatisfactory. When all avenues have been explored, the final diagnosis is too often tentative and presumptive. The development of what is almost a specific therapy for localized tuberculosis has added the therapeutic trial test to the diagnostic armamentorium and usually makes it possible to confirm or reject a shaky presumptive diagnosis. The various approaches to the diagnosis are (1) clinical picture. (2) elimination of other probable etiological factors, (3) evidence of collateral tuberculous infection, (4) immunological evidence of a tuberculous infection and (5) the therapeutic trial test.
It is with the physical evidence of a collateral tuberculous infection that we are interested.
Materials and Methods
150 cases of suspected ocular manifestations of tuberculosis were collected from the records of Kasturba General Hospital which maintains the International System of record keeping. These cases were collected over a period of 4 years (May 1961 to December 1965). Only those cases that were regularly under observation and fully investigated and followed up have been taken for this study. The cases were of (1) phlyctenulosis, mostly recurrent (2) granuloma conjunctiva, (3) scleritis, (4) episcleritis, (5) sclerosing, keratitis, (6) deep interstitial keratitis, (7) granulomatous and non-granulomatous iridocyclitis, (8) generalised uveitis, (9) choroiditis, (10) optic neuritis, (11) recurrent vitreous haemorrhage, (12) extra ocular palsies.
The following investigations were done (1) Total W.B.C. count, (2) Difrential count, (3) E.S.R., (4) V.D.R.L. and Kahn's floculation test. (5) Urine for albumin, sugar and deposits, (6) Mantoux test. After these tests, if the tuberculous etiology was considered as a distinct possibility, they were further investigated as mentioned below. In this investigation if V.D.R.L. and Kahn's tests were positive, and a history of exposure was acknowledged, the cases were rejected. Similarly, if Mantous test were negative, the cases were rejected, since low degree cutaneous reactions are of neither positive nor negative value.-WOODS (1961).
The cases thus selected were subjected to a medical survey by a consulting physician. This included examination of all systems especially respiratory and glandular. Particular note was taken of cervical and axillary lymphnodes. In the history, a family history of close and constant contact with a tuberculous patient was enquired. A history of evening rise of temperature, sweating, loss of weight and loss of appetite were particularly noted. A chest X-Ray (postero anterior view) was taken as a routine and in many cases biopsy of the glands was done.
Finally if a systemic active focus was found, the patient was subjected to a therapeutic trial test consisting of streptomycin injection daily and isoniazid 100 mg three times a day for atleast one month. If both ocular and systemic clinical picture showed definite improvement, the case was taken as ocular tuberculosis associated with active systemic focus.
The following 3 cases emphasize the "benign" nature of the systemic tuberculosis.
1. Mrs. U.D., 30 years old, female came to the Hospital with a history of joint pain in multiple joints and high fever for 6 days. The case was investigated by a responsible physician. Chest X-ray was taken and E.S.R, was done. The disease was diagnosed as rheumatic fever. During the course of treatment, the patient developed sclerosing keratitis which was attributed to the rheumatic fever. When the ocular lesion tended to recur in spite of treatment for rheumatic fever, a second thought was given. A second "head to foot" examination was made with special attention to the possibility of systemic tuberculosis. That revealed matted glands in the left axilla. The biopsy showed tubercular adenitis. Anti-tuberculous treatment was given resulting in amelioration of her joint pains, fever, and ocular symptoms.
2. Shree K.V.A.-25 year old, Male, came to the Eye O.P.D. with pain in the right eye of 7 days duration. Sudden loss of vision, right eye-7 days. Headache-2 weeks. On examination, the right eye had only perception of light, right pupil showed ill-sustained reaction; fundus was normal. A diagnosis of retrobulbar neuritis was made. A lumbar puncture revealed C.S.F. under pressure, WBC 290/cmm, mostly lymphocytes, (Polymorphs 9%, lymphocytes 91%), total proteins 120 mg%, sugar 65 mg chlorides 750 mg%, Pandy's test positive and VDRL-negative. A diagnosis of tuberculosis was made, and antituberculous treatment improved the clinical picture fully. Later, the family physician of the patient revealed to us that the patient had loss of appetite, loss of weight, increased sweating, irregular fever for the last 6 months, and it was attributed to "Neurosis". Six months later, the mother of the patient (with whom he was living) submitted to the hospital for the treatment of glandular tuberculosis and tuberculosis of the spine.
3. K.M., 17 years old male, had a deep corneal opacity of 8 years duration. Its vascularity in the form of a loop and arborization interested the house-surgeon, who made a head to foot clinical examination of the patient. A hypopigmented patch was found over the back which was proved to be tuberculous in nature by biopsy. Both the corneal opacity and the hypopigmented patch over the back improved with anti-tuberculous line of treatment. (SRINIVAS RAO and SHANKAR BHATT-1962).
The observations are recorded in [Table 1], some of which are illustrated in Plates 1-4.
The incidence of systemic active lesion in cases of suspected ocular tuberculosis was 34 out of 150 (22.6%) and in 3 (2%), healed but gross lesions were found. Out of the 34, 21 proved to be glandular, 4 pulmonary, 4 progressive primary complex and 5 in other sites.
There would have been a higher percentage of incidence, if the examination had included more thorough investigations such as both anteroposterior and lateral views of the chest culture and animal inoculations of the gastric washings in suspicious cases. In addition, repeated clinical review of the remaining 116 cases with periodic X-Rays and ESR test would have probably revealed some more active lesions.
The incidence of glandular tuberculosis would also have been higher, had routine biopsy been done in all cases where glands were palpable.
In almost all cases the systemic lesion tended to be "benign" in the sense, we could have easily missed it, had we not looked for it.
The Kasturba General Hospital has about 640 patients of systemic tuberculosis in the list of regular treatment, yet none (except one) had any ocular symptoms attributable to tuberculosis. However, it has to be admitted that they were not regularly checked by ophthalmologists. Only in one case, the patient who had come for pulmonary, tuberculosis had an eye complaint (phlyctenule) attributed to tuberculosis.
The type of ocular lesions that were associated with systemic tuberculosis mostly were of phlyctenulosis. Thus, out of 42 cases of phlyctenulosis, 15 had systemic lesions, out of 17 of sclerosing keratitis, 11 had tuberculosis and out of 7 of recurrent vitreous haemorrhage, systemic lesions were found in 3. [Table 1]. At least in these types of cases, it is a good plan to exclude the possibility of an active systemic focus. It is of interest to note that all the 4 progressive primary complex cases were associated with phlyctenulosis, and 3 out of the 4 were of an age less than 5 years. In spite of all the talk about granulomatous and non-granulomatous iridocyclitis, we were able to demonstrate systemic active focus in only one case out of 31 of iridocyclitis.
Another feature of this work is the eye findings have led to the detection of 4 insufficiently and irregularly treated cases of systemic tuberculosis.
Lastly the choroidal tubercles which are supposed to have some diagnostic significance were not recorded in this series, showing thereby that its value as a diagnostic aid in systemic tuberculosis is insignificant.
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