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 Table of Contents  
BRIEF COMMUNICATIONS
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 40-43

Journey of choroidal tubercle to choroidal granuloma


1 Department of Ophthalmology, Adesh Institute of Medical Sciences and Research, Bathinda, Punjab, India
2 Department of Pediatrics, Adesh Institute of Medical Sciences and Research, Bathinda, Punjab, India
3 Department of Ophthalmology, Gian Sagar Medical College and Hospital, Patiala, Punjab, India

Date of Submission15-Feb-2021
Date of Decision08-Jun-2021
Date of Acceptance08-Jun-2021
Date of Web Publication3-Feb-2022

Correspondence Address:
Rajwinder Kaur
Department of Opthalmology, Adesh Institute of Medical Sciences and Research, Barnala Road, Bathinda, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_23_21

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  Abstract 


Choroidal tubercles may be unilateral or bilateral and appear as a polymorphic yellowish lesion with discrete borders. Tubercles can arise early in the stages of progression of tuberculosis (TB) and are indicative of hematogenous dissemination seen in acute military TB. Choroidal granuloma is seen in chronic TB in response to antitubercular treatment. We report a case of a 14-year old girl who presented with fever, altered sensorium, and irritability for 1 week. Fundus examination revealed bilateral multiple choroidal tubercles. Antitubercular treatment was started after magnetic resonance imaging head and cerebral spinal fluid cytology confirmed the diagnosis of disseminated TB. Enhanced depth imaging optical coherence tomography was done on follow-up visits to see the stages of progression or regression of choroidal tubercle after the treatment. This is a rare case, reporting the transition of choroidal tubercle into choroidal granuloma, which is demonstrated with serial imaging using various modalities.

Keywords: Choroidal granuloma, choroidal tubercle, disseminated


How to cite this article:
Kaur R, Singh H, Khan B, Sehgal A, Aggarwal A. Journey of choroidal tubercle to choroidal granuloma. J Clin Ophthalmol Res 2022;10:40-3

How to cite this URL:
Kaur R, Singh H, Khan B, Sehgal A, Aggarwal A. Journey of choroidal tubercle to choroidal granuloma. J Clin Ophthalmol Res [serial online] 2022 [cited 2022 May 29];10:40-3. Available from: https://www.jcor.in/text.asp?2022/10/1/40/337190



Ocular tuberculosis (TB) occurs in 1% of all diagnosed cases of TB. It can be caused by hematogenous spread or due to immune-mediated reaction that is Type IV hypersentivity reaction to latent TB elsewhere in the body.[1] Ocular TB can involve any tissue of the eyes and the orbit. The rich vascularity of the uvea permits the easy hematogenous spread of infections from a primary focus in the body. Intraocular TB has shown a wide spectrum of uveitic entities varying from anterior uveitis, intermediate uveitis, posterior uveitis, and panuveitis. In tuberculous posterior uveitis, the ocular changes can be divided into four groups: choroidal tubercles, choroidal tuberculoma, subretinal abscess, and serpiginous-like choroiditis.[2]

Smartphone fundus imaging using MII Ret Cam in bed-ridden patients can assist in practicing evidence-based medicine by the demonstration of fundus findings to the patients/patient's attendants and monitoring disease and treatment response in cases of uveitis. Spectral domain optical coherence tomography (SD-OCT) enables high visualization of the retina and choroid. Enhanced depth imaging (EDI-OCT) is a useful imaging technique in the follow-up of tubercular choroiditis.


  Case Report Top


A 14-year-old female was admitted to the pediatric intensive care unit with a history of fever on and off for 1 month. History revealed episodes of headache, nausea, and vomiting for 1 week. She was admitted in a state of altered sensorium and irritability. Glasgow coma scale was 12/15. Meningeal irritation signs such as Kernig's, Brudzinski, and neck rigidity were present. Deep tendon reflexes showed a brisk response. Pupils were bilateral equal, normal in size, and reacting to light equally. Dilated fundus examination before lumbar puncture was done, which revealed multiple choroidal tubercles with disc edema in both eyes. Fundus picture was taken with MII Ret Cam as a patient was critically ill and was bedridden [Figure 1]a and [Figure 1]b. The patient was investigated to find out the source of dissemination. Chest X-ray was normal. Contrast-enhanced magnetic resonance imaging revealed 3–7 mm nodular and ring-enhancing lesions in bilateral cerebral and cerebellar hemispheres and pons. Acute lacunar infarcts were also seen in the right parietal and left frontal lobe. Findings were suggestive of granulomatous etiology likely tubercular granuloma with vasculitis [Figure 2]. Cartridge-based nucleic acid amplification test revealed Mycobacterium tuberculosis. Erythrocyte sedimentation rate was raised to 66 mm/h. Cerebral spinal fluid (CSF) cytology was suggestive of TB; the CSF showed predominantly lymphocytic pleocytosis, an elevated protein level, and low glucose level. A diagnosis of disseminated TB with tubercular meningitis with bilateral choroidal tubercle was made. It should be suspected in any case of visual disorders in endemic areas. The patient was started on antitubercular therapy consisting of rifampicin 150 mg once daily, isoniazid 75 mg once daily, pyrazinamide 400 mg once daily, and ethambutol 275 mg once daily for 2 months, followed by rifampicin and isoniazid for 10 months by a pediatrician. Oral prednisolone (1 mg/kg/day) in tapering doses and epileptics was also started. The case was reviewed at the time of discharge, fundus photograph was taken [Figure 1]c and [Figure 1]d, and EDI-OCT scans passing through choroidal tubercles were taken. Fundus photographs revealed tubercles varying in size ranging from 300 μm to 3000 μm were located in the posterior pole. The size of the biggest tubercle which had changed to granuloma size was 3148 μm × 555 μm. Progression of tubercle to granuloma which is suggested by hemorrhage on its surface, and surrounding pocket of subretinal fluid (SRF) was noticed within 2 weeks of treatment [Figure 3]a. Fundus autofluroscence imaging showed hyperautofluorescent lesion with central hypoautofluorescence and halo of SRF [Figure 3]b. Near-infrared reflectance (NIR) imaging revealed hyperreflective lesion with a hyporeflective halo [Figure 3]c. EDI-OCT showed the dimensions of choroid granuloma with the contact zone between the retinal pigment epithelium–choriocapillaries and the neurosensory retina over the mass [Figure 3]d. Three dimensional scan showed elevation in the area of granuloma with SRF in the right eye [Figure 3]e and healing tubercle in the left eye [Figure 3]f. Visual acuity remained 20/20 throughout the first visit.
Figure 1: (a and b) Fundus photograph of shows choroidal tubercles in both eyes (photography done MII Ret Cam in pediatric intensive care unit. (c and d) Fundus photograph taken on fundus camera which shows papilledema with healing tubercles both eyes except one tubercle which progressed to choroidal granuloma

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Figure 2: Contrast-enhanced magnetic resonance imaging revealed 3–7 mm nodular and ring enhancing lesions in bilateral cerebral and cerebellar hemispheres and pons. Acute lacunar infarcts were also seen in the right parietal and left frontal lobe. Chest X-ray was normal. Findings were suggestive of granulomatous etiology likely tubercular granuloma with vasculitis

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Figure 3: Multimodal imaging of a tuberculous choroidal granuloma (a) Color photograph shows granuloma with pocket of subretinal fluid. (b) Fundus autofluroscence imaging shows hyperautofluorescent lesion with central hypoautofluorescence. (c) Near-infrared reflectanceimaging revealed hyperreflective lesion with a hyporeflective halo. (d) Enhanced depth imaging spectral-domain optical coherence tomography through the central section of granuloma shows smooth choroidal elevation with localized obscuration of choroidal detail and secondary outer retinal disruption of the photoreceptor ellipsoid through outer nuclear layer by hyperreflective infiltrate (contact sign). Lobulated hypo/isoreflective choroidal lesion with loss of vascular pattern and dome-shaped elevation of the overlying retina. (e) Three-dimensional view of choroidal granuloma with a tiny pocket of subretinal fluid at the apex of the lesion and hyperreflective infiltrate with localized disruption of the outer retina, and retinal pigment epithelium was noted suggestive of activity. (f) Demonstrated resolution of the tubercle with treatment, restoring the normal choroidal architecture with increased signal transmission effect was seen beneath the lesion

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  Discussion Top


The term “disseminated TB” denotes the involvement of two or more noncontiguous organs in a single patient.[3] Ocular involvement in disseminated TB results from hematogenous spread of tubercular bacilli. A choroidal tuberculoma is one of the most common forms of ocular TB, and it is probably due to the high blood supply of the choroid. Choroidal tubercles, which are discrete yellowish lesions with indistinct borders varying in number and size seen predominantly at the posterior pole, may be earliest ocular presentation of the disseminated TB.[4] Occasionally, a tubercle may continue to grow into tuberculoma. As they resolve, the margins become sharp and distinct, and the center turns yellow or white with a surrounding halo of pigmentation, ultimately leaving an atrophic scar.[5] Tubercles seen in our case responded well to treatment, and healed lesions showed atrophic areas with variable pigmentation seen on SD-OCT.

Rarely, a tuberculoma may be the presenting sign in a patient with no evidence of systemic disease. The tuberculoma may present as a solitary mass, hemorrhage, and retinal folds may be seen on the tuberculoma surface. It may measure from 4 to 14 mm in size and with SRF around it mimicking as intraocular tumor or infective abscess. In response to the treatment, choroidal tubercle progresses to form choroidal granuloma with visible blood vessel on its surface and SRF pocket well documented.[6] This is first time reported with clinical documentation of the course of choroidal tubercle with the help of multimodal imaging, where all other tubercles were healing, and one tubercles progressed to form choroidal granuloma.

With the advent of EDI-OCT, characterization of the choroidal lesion has evolved that enables imaging of the choroid and sclera. It also enables morphological evaluation of lesions, precise localization and measurement, and monitoring the response to the treatment. NIR imaging provides high-resolution enface images of subretinal pathologies demonstrating choroidal tubercles.[7],[8] A distinctive feature of attachment between retinal pigment epithelium–choriocapillaries layer and overlying neurosensory retina is described as “contact sign” by Mistry et al. This was surrounded by a pocket of SRF and inflammatory infiltrate in the deep retina layers.[9] It was clearly documented in our case. This is one of the rare cases reporting the transition of choroidal tubercle into choroidal granuloma in a case of disseminated TB in 2-week time in response to ATT. EDI-OCT helped us in monitoring the course of choroidal tubercle and choroidal granuloma.

A recent case reported presumed vascularized choroidal tubercular granuloma successfully treated with three intravitreal injections of bevacizumab (Avastin).[10] Intravitreal anti-vascular endothelial growth factor (VEGF) agents result in a reduction in size, absorption of SRF, and normalization of choroidal thickness in tubercular choroidal granulomas. These agents cause resolution of granuloma when used as adjuncts to oral steroids and ATT. As the patient was maintaining 20/20 vision, intravitreal anti-VEGF was kept in plan.

It is concluded that imaging techniques such as smartphone fundus photography with MII Ret Cam helps in documenting important findings when the patient is immobile. EDI-OCT is an excellent method of monitoring the course and response to specific treatment.


  Declaration of patient consent Top


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 Top

1.
Babu MS, Murthy KV. The hidden clinical sign on fundoscopy. BJMP 2013;6:a625.  Back to cited text no. 1
    
2.
Annamalai R, Biswas J. Bilateral choroidal tuberculoma in miliary tuberculosis – Report of a case. J Ophthalmic Inflamm Infect 2015;5:4.  Back to cited text no. 2
    
3.
Iseman MD. Extrapulmonary tuberculosis in adults. A Clinician's Guide to Tuberculosis. 1st ed. Philadelphia: Lippincott Williams and Wilkins; 2000. p. 145-97.  Back to cited text no. 3
    
4.
Thompson MJ, Albert DM. Ocular tuberculosis. Arch Ophthalmol 2005;123:844-9.  Back to cited text no. 4
    
5.
Gupta V, Gupta A, Rao NA. Intraocular tuberculosis – An update. Surv Ophthalmol 2007;52:561-87.  Back to cited text no. 5
    
6.
Sridharan S, Biswas J. Ocular tuberculosis: An update. Expert Rev Ophthalmol 2007;2:845-60.  Back to cited text no. 6
    
7.
Lekha T, Karthikeyan R. Multimodal imaging of choroidal tubercles. Indian J Ophthalmol 2018;66:995-6.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Agarwal A, Mahajan S, Khairallah M, Mahendradas P, Gupta A, Gupta V. Multimodal imaging in ocular tuberculosis. Ocul Immunol Inflamm 2017;25:134-45.  Back to cited text no. 8
    
9.
Mistry S, Majumder PD, Biswas J. Serial swept-source optical coherence tomography: Tale of a choroidal tuberculoma. Oman J Ophthalmol 2019;12:42-5.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Babu K, Murthy P, Murthy K. Intravitreal bevacizumab as an adjunct in a patient with presumed vascularised choroidal tubercular granuloma. Eye 2010;24:397-9.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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