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CASE REPORT
Year : 2018  |  Volume : 11  |  Issue : 4  |  Page : 344-347  

Tubercular scleritis: A rare presentation


Department of Ophthalmology, Andaman and Nicobar Islands Institution of Medical Science, Port Blair, Andaman and Nicobar Islands, India

Date of Web Publication2-Aug-2018

Correspondence Address:
Sujit Das
Department of Ophthalmology, Andaman and Nicobar Islands Institution of Medical Science, Port Blair, 744104, Andaman and Nicobar Islands
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.MJDRDYPU_235_17

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  Abstract 


Tubercular scleritis is a rare condition and the sclera may be involved by direct spread from the adjacent ocular structures or more commonly by hematogenous spread as a secondary involvement. The present case of sputum-positive pulmonary tuberculosis (TB) with diabetes presented with features of anterior scleritis, anterior uveitis, and peripheral vasculitis and was well managed with antitubercular therapy, systemic analgesic (indomethacin), systemic short course of corticosteroid, and antidiabetic drugs. Systemic steroid is always reserved for patients with severe scleritis/necrotizing scleritis, and it was a challenge for us to start systemic steroid in a patient with sputum-positive pulmonary TB.

Keywords: Tubercular ocular manifestation, tubercular scleritis, scleritis


How to cite this article:
Das S. Tubercular scleritis: A rare presentation. Med J DY Patil Vidyapeeth 2018;11:344-7

How to cite this URL:
Das S. Tubercular scleritis: A rare presentation. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2019 Oct 22];11:344-7. Available from: http://www.mjdrdypv.org/text.asp?2018/11/4/344/238175




  Introduction Top


Scleritis is a painful inflammatory process in the sclera that may involve the cornea and the underlying uvea.[1] The etiology is commonly idiopathic or autoimmune, but some cases are associated with systemic infection such as tuberculosis (TB). It is a serious ocular condition that can lead to vision loss and therefore requires early diagnosis and treatment. Scleritis is usually suspected from the clinical history and confirmed by its characteristic clinical signs. Fifty percent of patients with scleritis are diagnosed with an associated systemic disease including autoimmune conditions and infections.[2] TB-related scleritis is an uncommon ocular inflammatory disorder that presents challenges in diagnosis and management for both ophthalmologists and infectiologists. Ocular TB affects the anterior and posterior segments of the eye in immune-compromised patients.[3]


  Case Report Top


A 45-year-old male presented to us with a complaint of severe headache and eye pain with redness of the left eye for the past 15 days. Pain was associated with photophobia and watering. There was no discharge. Pain was aggravated with ocular movements. There was no history of any associated fever, weight loss, joint pain and deformity, skin rash, or any connective tissue disease. There was no history of any similar episode in the past. He is a known case of diabetes mellitus and pulmonary TB (sputum positive) and was on tablet glimepiride (1 mg twice daily), metformin (500 mg twice daily), and antitubercular drug (rifampicin, 10 mg/kg daily; isoniazid, 5 mg/kg daily; pyrazinamide, 20 mg/kg daily, and ethambutol, 15 mg/kg daily continued for 2 months, followed by rifampicin, isoniazid, and ethambutol for 4-month regimen) for the past 3 months. On examination, best-corrected visual acuity was 6/9 in both eyes; intraocular pressure was 15 mmHg in both eyes. Lids were normal with full extraocular movements with pain. Cornea showed row of infiltration inferiorly [Figure 1] with keratic precipitates [Figure 2]. On phenylephrine test the there was no blanching of the supero-temporal congested deep blood vesscles-suggestive of scleritis [Figure 3]. Slit-lamp examination showed no displacement of the beam. Anterior chamber showed moderate reaction with 2+ cells [Figure 2] and no iris pigments over the endothelium. Pupil was normal in size and briskly reacting to light. On fundus examination, there was normal optic disc and peripheral vasculitis with normal posterior pole [Figure 4]. Globe was tender on palpation with severe frontal sinus tenderness without any cervical lymphadenopathy. Department of Otolaryngology opinion was taken. X-ray peripheral nervous system was found to be normal, and no treatment was started from their side. Fundus fluorescence angiography showed block fluorescence and no active leakage [Figure 5]. A diagnosis of anterior scleritis with vasculitis was made, and the patient was started on tablet indomethacin (75 mg) once daily with tablet ranitidine (150 mg twice daily), topical prednisolone acetate 1 drop 1 hourly, topical nepafenac 1 drop three times/day, topical homatropine 1 drop three times/day, and topical lubricating drug. Chest physician's opinion regarding systemic steroid was taken and started on systemic prednisolone (1 mg/kg/day with rapid tapering every 3 days). The patient had positive Mantoux test [Figure 6], and chest X-ray was suggestive of TB [Figure 7]. Contrast-enhanced computed tomography chest showed fibrosis with pleural thickening [Figure 8]. Complete blood count showed that high erythrocyte sedimentation rate was 45 and rest all were normal. Sugar was normal, rheumatoid factor was negative, antinuclear antibody (factor) was negative, anti-nucleotide cytoplasmic antibody was negative, and angiotensin-converting enzyme estimation was normal. Based on clinical findings and history, tubercular scleritis, sclerosing keratitis, and tubercular vasculitis were made which are rare presentations. On subsequent follow-up, the patient showed symptomatic improvement of ocular sign with disappearance of marginal infiltrate [Figure 9] and scleral inflammation [Figure 10].
Figure 1: Marginal corneal infiltrate

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Figure 2: Keratic precipitates

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Figure 3: Scleritis

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Figure 4: Peripheral vasculitis

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Figure 5: Fundus fluorescein angiography showed block fluorescein

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Figure 6: Mantoux test positive

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Figure 7: Tubercular chest X-ray

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Figure 8: Contrast-enhanced computed tomography chest showed pleural thickening with fibrosis

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Figure 9: Disappearance of corneal infiltrate

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Figure 10: Scleral inflammation reduced

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  Discussion Top


Tubercular scleral involvement may be anterior scleritis, posterior scleritis, or necrotizing scleritis.[3] Among scleritis, anterior scleritis is the most common pattern of the disease.[1] Ocular TB has always been considered rare,[3] yet its incidence has varied widely across time, patient populations, and geography. There is no pathognomonic ophthalmic finding for ocular TB. A detailed history of the patient is very important, to suspect ocular TB. The history or medical history of TB, family history, or any contact with tubercular patient is important to rule out the disease.[4] Diagnosis of tubercular scleritis is based on positive history of tuberculosis, positive Mantoux test, positive chest X-ray, clinical features of scleritis and quick response to anti-tubercular therapy (ATT).[5] Anterior scleritis is further subdivided into diffuse, nodular, necrotizing with inflammation, and necrotizing without inflammation (scleromalacia perforans).[6] In eyes with scleritis, the inflammatory process may extend to adjacent structures, causing several complications that may lead to loss of vision.[7] Anterior scleritis can be associated with anterior uveitis, cataracts, glaucoma, and peripheral keratopathy.[7] Specific complications of posterior scleritis can include exudative retinal detachment, optic disk edema, cystoid macular edema, and choroidal folds.[8] Ocular MTB infection is most often a result of hematogenous dissemination from a distant site (such as lungs). Infection may also occur by direct extension from the surrounding tissue or by direct inoculation.[9] TB-related ocular inflammation mainly accompanies latent TB (LTB),[9] wherein the patient is infected with MTB but does not have active TB disease.[9] It is estimated that LTB affects one-third of the world's population and about 10% of patients with LTB will go on to develop active TB at a later stage of their life.[9] Ocular TB is treated with medical ATT similar to that for pulmonary TB.[10] The Centers for Disease Control and Prevention recommends the use of all four drugs (isoniazid, rifampicin, pyrazinamide, and ethambutol) for an initial 2-month period followed by a choice of different options over the next 4–7 months. A low dose of steroid is sometimes given concomitantly with antitubercular therapy for 4–6 weeks to protective tissue damage from delayed hypersensitivity reactions.[10]


  Conclusions Top


TB, including latent form, is a possible infectious cause of scleritis and other ocular inflammatory manifestations. Delayed diagnosis can lead to vision loss and systemic complications of the infection. TB-related ocular inflammation is a challenging clinical entity that may be difficult to diagnose and manage. However, a favorable response to ATT without relapse is taken as evidence of the disease.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for images and other clinical information to be reported in the journal. The patient understands that name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Okhravi N, Odufuwa B, McCluskey P, Lightman S. Scleritis. Surv Ophthalmol 2005;50:351-63.  Back to cited text no. 1
    
2.
Smith JR, Mackensen F, Rosenbaum JT. Therapy insight: Scleritis and its relationship to systemic autoimmune disease. Nat Clin Pract Rheumatol 2007;3:219-26.  Back to cited text no. 2
    
3.
Alvarez GG, Roth VR, Hodge W. Ocular tuberculosis: Diagnostic and treatment challenges. Int J Infect Dis 2009;13:432-5.  Back to cited text no. 3
    
4.
Liang L, Xu MF, Jiang FG. Ocular tuberculosis. Am J Case Rep 2009;10:231-5.  Back to cited text no. 4
    
5.
Bramante CT, Talbot EA, Rathinam SR, Stevens R, Zegans ME. Diagnosis of ocular tuberculosis: A role for new testing modalities? Int Ophthalmol Clin 2007;47:45-62.  Back to cited text no. 5
    
6.
Sims J. Scleritis: Presentations, disease associations and management. Postgrad Med J 2012;88:713-8.  Back to cited text no. 6
    
7.
Tuft SJ, Watson PG. Progression of scleral disease. Ophthalmology 1991;98:467-71.  Back to cited text no. 7
    
8.
Litwak AB. Posterior scleritis with secondary ciliochoroidal effusion. J Am Optom Assoc 1989;60:300-6.  Back to cited text no. 8
    
9.
Chuka-Okosa CM. Tuberculosis and the eye. Niger J Clin Pract 2006;9:68-76.  Back to cited text no. 9
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10.
Bansal R, Gupta A, Gupta V, Dogra MR, Bambery P, Arora SK, et al. Role of anti-tubercular therapy in uveitis with latent/manifest tuberculosis. Am J Ophthalmol 2008;146:772-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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