An unusual presentation of intraocular tuberculosis in a monocular patient : clinicopathological correlation

Background: Lack of uniform diagnostic criteria often poses a challenge in the diagnosis and management of tubercular uveitis. The index case describes an unusual presentation of tubercular panuveitis initially misdiagnosed as sympathetic ophthalmia, where the appropriate diagnosis was made using various imaging and laboratory investigations. Results: A 52-year-old Indian woman underwent multimodal imaging, extensive clinical and laboratory work-up, and analysis of microbiological and histopathological specimens. At presentation, her best-corrected visual acuity (BCVA) was 20/30 in OD and no perception of light in OS. Ocular examination revealed multiple grayish-yellow choroiditis lesions resembling Dalen-Fuch’s nodules, vitritis, and disc edema. Diagnosis of sympathetic ophthalmia was made and patient treated with intravenous and oral corticosteroids and immunosuppressive therapy. After an initial favorable response, the lesions progressively increased with worsening of vitritis. Due to worsening of chorioretinal lesions which were atypical for sympathetic ophthalmia, further investigations were performed that revealed positive tuberculin skin test and contrast-enhanced computerized tomography chest showed calcified mediastinal lymph nodes. Enucleation of OS confirmed acid-fast bacilli on Ziehl-Neelsen staining, tubercular granulomas on histopathology, and positive polymerase chain reaction. Anti-tubercular therapy and oral steroids were started with good healing response. Conclusions: Tubercular uveitis may have protean clinical manifestations. Thorough clinical evaluation and molecular/histopathological evaluation helps in establishing the diagnosis and the institution of appropriate therapy.