Anterior tuberculous scleritis: A diagnostic challenge

Clinical profile of patients with anterior nodular scleritis in India

Purpose:

To report the clinical profile of a series of anterior nodular scleritis in Indian population.

Methods:

We conducted a retrospective review of medical records of 140 eyes of 123 consecutive patients with nodular scleritis who presented to a tertiary eye care institute between 2007 and 2018.

Results:

The mean age at presentation was 46.8 ± 13.1 years and 70.7% of the patients were female. Bilateral involvement was observed in 14% patients. The most common presenting symptom was redness (92.6%) and ocular pain (69.1%). Twenty-seven patients (22%) had some systemic association and rheumatoid arthritis (5%) was the most common autoimmune disease. Presumed ocular tuberculosis was diagnosed in 13% patients. Methotrexate was the most common immunosuppressive used in these patients and an additional immunosuppressive was required in 6.5% patients. Recurrence of inflammation was observed in 74.8% patients. Deterioration of vision noted in 2.8% eyes.

Conclusion:

Tuberculosis remains an important cause of nodular scleritis in India. Recurrence of scleritis is common in nodular scleritis and cases with non infectious nodular scleritis often require treatment with immune suppressives.

Frequently Relapsing Anterior Nodular Scleritis as the Initial Presentation of a Lethal Systemic Infection: Disseminated Tuberculosis with HIV Coinfection

Background

Scleritis is a painful inflammatory ocular disease often associated with an underlying systemic illness mostly having an autoimmune aetiology. Tuberculosis usually presents as pulmonary infection, and the ocular presentation is considered to be rare. Case presentation. We present a male who developed prolonged pyrexia following systemic steroids while being investigated for a frequently relapsing anterior scleritis. Biopsy of sclera demonstrated acid-fast bacilli, and histology of sclera and lymph node showed granulomatous inflammation with caseation. Contrast CT demonstrated mediastinal and visceral lymphadenopathy with pulmonary changes suggesting disseminated tuberculosis. Later, Western blot confirmed coinfection with HIV with a CD4 count of 71 cells/mm³. He was treated with antituberculous medications, and then HAART was initiated within two months. He showed good response and showed a partial resolution of scleritis at the end of two months.

Conclusion

Tuberculosis tends to occur in unusual sites when coinfected with HIV. Scleritis is a rare extrapulmonary manifestation of tuberculosis. High degree of suspicion is critical in making diagnosis and commencing early treatment.