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| CASE REPORT |
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| Year : 2022 | Volume
: 60
| Issue : 1 | Page : 98-100 |
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Presentation of sclerouveitis with features of Vogt Koyanagi Harada syndrome and ocular tuberculosis – A Rare Combination
Purva Vijay Deore, Syed Faraaz Hussain, Mamta Agarwal, Yogya Reddy
Department of Ophthalmology, MGM Institute of Health Sciences, Navi Mumbai, Maharashtra, India
| Date of Submission | 09-Sep-2021 |
| Date of Decision | 19-Oct-2021 |
| Date of Acceptance | 28-Oct-2021 |
| Date of Web Publication | 22-Mar-2022 |
Correspondence Address:
Dr. Purva Vijay Deore
Flat No. 5, Nirganga Apartment, Hanuman Ghat, Gangapur Road, Nasik - 422 002, Maharashtra
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/tjosr.tjosr_137_21
Inflammation of sclera with involvement of uvea is an uncommon and underdiagnosed disease entity seen in an ophthalmological outpatient setting. A 34-year-old male presented with complaints of headache, redness, pain, photophobia, and blurring of vision in the left eye > right eye with associated tinnitus, decreased hearing, and recurrent severe headaches over 3 months. Detailed ophthalmological examination revealed signs of sclerouveitis. We thoroughly investigated the patient which revealed manifestations of incomplete VKH syndrome, along with strongly positive mantoux test hence, he was started on oral steroids under antituberculous treatment cover after physician consult. On follow-up, the patient was symptomatically better with resolution of inflammatory signs over a period of 3 months. The patient is being followed up by multispecialty approach to discern VKH manifestations of later disease.
Keywords: Sclerouveitis, tuberculosis, Vogt-Koyanagi-Harada syndrome
How to cite this article:
Deore PV, Hussain SF, Agarwal M, Reddy Y. Presentation of sclerouveitis with features of Vogt Koyanagi Harada syndrome and ocular tuberculosis – A Rare Combination. TNOA J Ophthalmic Sci Res 2022;60:98-100 |
How to cite this URL:
Deore PV, Hussain SF, Agarwal M, Reddy Y. Presentation of sclerouveitis with features of Vogt Koyanagi Harada syndrome and ocular tuberculosis – A Rare Combination. TNOA J Ophthalmic Sci Res [serial online] 2022 [cited 2022 Jun 29];60:98-100. Available from: https://www.tnoajosr.com/text.asp?2022/60/1/98/340351 |
| Introduction | |  |
Tuberculosis (TB) is a severe multisystemic disease affecting mainly the lungs and other organs, including eye. Nearly one-third of the world's population is infected with Mycobacterium tuberculosis.[1] Sclerouveitis is commonly related to underlying systemic disease, including autoimmune, idiopathic, and rarely infective. Sclerouveitis due to TB is a rare entity with only a few case reports described. Sclerouveitis due to TB presents with severe persistent and recurrent decrease in vision, ocular pain, deep vascular congestion, bluish-gray discoloration of sclera, granulomatous anterior uveitis, myositis, uveal effusion, papilledema, choroidal folds, and exudative retinal detachment.[2] Vogt-Koyanagi-Harada (VKH) syndrome also is characterized by granulomatous panuveitis with iridocyclitis, exudative retinal detachments, diffuse choroidal swelling, and optic disc hyperemia.[2] We report a case of sclerouveitis due to suspected TB presenting as a primary manifestation of incomplete VKH syndrome causing a diagnostic dilemma. Although infective cause is relatively rare, it is important in the developing world, especially in areas with endemic TB.
| Case Report | | |
A 34-year-old male presented to us with complaints of headache, painful blurring of vision with redness, and photophobia in the left eye (LE) > right eye (RE) for the past 3 months. The patient also gave a history of ringing in both ears for the past 3 months. The patient gave a history of brother diagnosed with pulmonary TB 6 months ago with positive contact history. The patient visited a local ophthalmologist for above-mentioned complaints, who prescribed him intravenous steroid followed by oral steroids and lubricating eye drops. He was not relieved by the medication and presented to us 3 months after symptom onset with flare-up of symptoms.
On ophthalmological examination, vision in the RE was FC at 2 m and LE vision was FC at 3 m with near vision in both eyes being N.36. On slit-lamp examination, the patient had deep vascular congestion, scleral thickening, and clear cornea, anterior chamber had +2 cells in the RE and +3 cells in the LE, and rest of anterior-segment examination including pupils were normal. Fundus examination revealed hyperemic swollen disc, with multiple choroidal folds around macula and optic disc and areas of exudative retinal detachment in the RE > LE along with shifting fluid.
Fundus photograph was taken after 2 weeks of the first consultation of a patient with us, after the resolution of cells and flare [Figure 1] and [Figure 2]. | Figure 1: Fundus photograph of the right eye showing choroidal folds and multiple exudative retinal detachments
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 | Figure 2: Fundus photograph of the left eye showing choroidal folds and multiple exudative retinal detachments
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Ultrasonography B scan showed sclerochoroidal thickening with widening of subtenons space. OCT showed choroidal folds and loss of normal vasculature in both eyes with macular edema in LE [Figure 3] and [Figure 4]. | Figure 3: Ultrasonography B scan indicating increased scleral thickness in right eye
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 | Figure 4: Ultrasonography B scan indicating increased scleral thickness in left eye
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Fundus fluorescein angiography revealed multiple retinal pigment epithelium level hyperfluoroscent leaks with pooling in areas of exudation [Figure 5] and [Figure 6]. | Figure 5: Fundus fluorescein angiography of the right eye revealing multiple retinal pigment epithelium level hyperfluoroscent leaks with pooling in areas of exudation
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 | Figure 6: Fundus fluorescein angiography of the left eye revealing multiple retinal pigment epithelium level hyperfluoroscent leaks with pooling in areas of exudation
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Hematological investigations revealed elevated ESR with normal serum ACE and serum lysozyme levels. His rheumatoid factor, serum antinuclear antibodies, and serum HLA B27 were negative. Cerebrospinal examination revealed no abnormality. Mantoux test revealed strongly positive 20 by 35 mm induration, but chest X-ray was normal.
ENT consult revealed moderate SNHL. Neurology also suspected incomplete VKH syndrome.
Consultation with a chest physician was done, and the patient was started on antituberculous treatment (ATT). We started the patient on topical cycloplegic, topical, and oral long-acting NSAIDs and oral steroids in the dose of 1.2 mg/kg/day.
The patient showed improvement in vision of both eyes being 6/9 with resolution of pain and redness when started with steroids and ATT at the end of 3 months. The patient has been counseled about the possibility of recurrences and the need for regular evaluation. The patient is being followed up by multispecialty including neurology, dermatology, and ENT approach to discern VKH manifestations of later disease.
| Discussion | | |
TB causing sclerouveitis is a diagnostic dilemma due to its rare nature and variable manifestations.[3] Scleritis differentials usually lead us to autoimmune or idiopathic causes, but we should always look for an infectious cause, especially TB in a developing country, as its incidence is increasing worldwide.[4]
In our case, according to the WHO, the patient was categorized as clinically diagnosed ocular TB and responded well after starting ATT. Due to the persistent headache and auditory symptoms, incomplete VKH syndrome was suspected.
Qian et al. described a case of uveitis associated with TB mistakenly diagnosed as VKH syndrome with resolution after starting ATT and steroids. Our case had similar features of incomplete VKH syndrome, which was treated with a working diagnosis of tuberculous sclerouveitis.[2]
Agarwal and Dutta Majumder described a 47-year-old female with optic disc edema, peripapillary subretinal fluid, and scattered areas of choroiditis. Her ultrasound B-scan showed sclerochoroidal thickening with widening of subtenon space, suggestive of posterior scleritis. Further investigations led to the diagnosis of tuberculous scleritis. As observed in our patient, there were no scattered areas of choroiditis and peripapillary subretinal fluid, but optic disc edema was present.[4]
| Conclusion | | |
VKH syndrome has similar manifestations as tuberculous sclerouveitis which can result in diagnostic dilemma. Hence, careful workup of the patient should be done. Our case highlights the importance of clinical suspicion of TB in the developing world scenario with overlapping VKH syndrome manifesting as sclerouveitis. Multispecialty approach and long-term monitoring are essential.
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 | | |
| 1. | Gupta V, Gupta A, Rao NA. Intraocular tuberculosis – An update. Surv Ophthalmol 2007;52:561-87.  |
| 2. | Qian TW1,Yu SQ1,Xu X1, A challenging case of tuberculosis-associated uveitis after corticosteroid treatment for Vogt-Koyanagi-Harada disease, International Journal of Ophthalmology, 18 Aug 2018, 11(8):1430-1432. DOI: 10.18240/ijo.2018.08.29. |
| 3. | Benson WE. Posterior scleritis. Surv Ophthalmol 1988;32:297-316. |
| 4. | Agarwal AM, Dutta Majumder P. Tubercular posterior scleritis: A case report and review of literature. Indian J Ophthalmol 2019;67:1362-5. [ PUBMED] [Full text] |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
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