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Dhiman R, Lakra S, Panda PK, Hemachandran N, Sharma S, Saxena R. Neuro-ophthalmic manifestations of tuberculosis. Eye (Lond) 2022; 36:15-28. [PMID: 34127839 PMCID: PMC8727585 DOI: 10.1038/s41433-021-01619-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 05/04/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023] Open
Abstract
Neuro-ophthalmic features are a known association in tuberculosis, especially common in central nervous system tuberculosis (CNS-TB). They are mostly the result of the visual pathway and/or ocular motor and other cranial nerve involvement. Furthermore, toxic optic neuropathy and paradoxical response to anti-tubercular drugs (ATT) are also not uncommon. The etiopathogenesis is by the complex interplay of various factors like exudates, vasculitis, arachnoiditis, presence of tuberculomas, hydrocephalus, brain infarcts and/or immune-mediated reaction. The entity often poses a diagnostic dilemma for the ophthalmologists/neuro-ophthalmologists and may lead to irreversible vision loss. The presence of neuro-ophthalmic features not only affect the visual outcome but are also predictors of systemic morbidity of the disease. Therefore, understanding and knowledge about this entity are necessary for the comprehensive management of the disease. While various forms of TB including CNS-TB have been well-dealt with in literature, little is discussed specifically about the neuro-ophthalmic manifestations of tuberculosis. Therefore, the purpose of this review is to highlight current understanding of the types of neuro-ophthalmic involvement in tuberculosis, its etiopathogenesis, diagnosis and management.
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Affiliation(s)
- Rebika Dhiman
- Neuro-Ophthalmology Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.
| | - Subodh Lakra
- Neuro-Ophthalmology Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Prateek Kumar Panda
- Pediatric Neurology Services, Department of Paediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Naren Hemachandran
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Sharma
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Rohit Saxena
- Neuro-Ophthalmology Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
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2
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Kumar S, Dhawan SR, Saini L, Singh P, Verma S, Singh M. Recurrent Paradoxical Tuberculosis with Chest Wall Abscess and Optochiasmatic Tuberculoma. J Pediatr Neurosci 2019; 13:500-502. [PMID: 30937100 PMCID: PMC6413591 DOI: 10.4103/jpn.jpn_90_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
New-onset clinical or radiological symptoms in a patient with tuberculosis pose diagnostic treatment challenges, which can be due to treatment failure, disease relapse, or paradoxical response. We describe an adolescent case of recurrent paradoxical response complicating tuberculous meningitis. The first paradoxical tuberculosis presented as chest wall abscess, which was complicated by uniocular, gradually progressive, painless loss of vision after 6 months.
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Affiliation(s)
- Suresh Kumar
- Department of Paediatric Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sumeet R Dhawan
- Department of Paediatric Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Lokesh Saini
- Department of Paediatric Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Paramjeet Singh
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay Verma
- Department of Paediatric Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Meenu Singh
- Department of Paediatric Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Machida M, Toyoda K, Matsuda M, Sumida K, Yamamoto A, Sakurai K, Oba H. Extensive perivascular dissemination of cerebral miliary tuberculomas: a case report and review of the literature. Acta Radiol Open 2018; 7:2058460118817918. [PMID: 30559977 PMCID: PMC6291888 DOI: 10.1177/2058460118817918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 11/14/2018] [Indexed: 11/15/2022] Open
Abstract
Cerebral tuberculosis (TB) presents most frequently as meningitis in the basilar cistern; however, it can also manifest in various other ways, such as localized encephalitis, abscess, and tuberculoma. Here, focusing on imaging findings, we report an immunocompetent case who demonstrated multiple parenchymal lesions and was diagnosed with cerebral TB after testing positive on QuantiFERON (QTF); her clinical signs/symptoms and laboratory findings responded well to anti-TB medication therapy. The patient was a 60-year-old woman with the chief complaints of headache and consciousness disturbance. On admission, cerebrospinal fluid (CSF) examination showed increased monocyte predominance. T2-weighted images showed multiple, widely distributed hyperintense lesions in the periventricular and deep white matter. Gadolinium-enhanced three-dimensional gradient echo T1-weighed images revealed numerous granules or faint, small, enhanced foci in lesions in the periventricular and deep white matter, central gray matter, and hippocampus. Some abnormal sulcal enhancement was detected in the pia mater, indicating meningitis. Clinically, the diagnosis was difficult to make, but as the QTF result was positive, anti-TB drugs were administered, after which both the symptoms and CSF cell count showed improvement.
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Affiliation(s)
- Munetaka Machida
- Department of Radiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Keiko Toyoda
- Department of Radiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Megumi Matsuda
- Department of Radiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Kaoru Sumida
- Department of Radiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Asako Yamamoto
- Department of Radiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Keita Sakurai
- Department of Radiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Hiroshi Oba
- Department of Radiology, Teikyo University School of Medicine, Tokyo, Japan
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Tengku-Fatishah A, Besari AM, Tharakan J, Shatriah I. Intraventricular Tuberculoma with Profound Visual Loss: A Case Report and Literature Review. Cureus 2018; 10:e2807. [PMID: 30123729 PMCID: PMC6093272 DOI: 10.7759/cureus.2807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Intracranial tuberculoma is a rare manifestation of tuberculosis involving the central nervous system. The involvement of the ventricular system is extremely uncommon. We describe a young woman with bilateral papilledema secondary to intraventricular tuberculoma with hydrocephalus. She was treated with anti-tuberculosis therapy and intravenous dexamethasone. Her visual acuity deteriorated after one month of treatment. We provide a literature review of this uncommon ocular sequelae.
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Affiliation(s)
- Amir Tengku-Fatishah
- Ophthalmology, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, USA
| | - Alwi Muhd Besari
- Medicine, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, MYS
| | - John Tharakan
- Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, MYS
| | - Ismail Shatriah
- Ophthalmology, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, MYS
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Pinto DS, Joseph T, George A, Hoisala RV. A case report of racemose pattern of intracranial tuberculoma with brain stem and hypophyseal involvement developing paradoxically during treatment. BJR Case Rep 2016; 2:20160034. [PMID: 30460000 PMCID: PMC6243367 DOI: 10.1259/bjrcr.20160034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 02/03/2016] [Accepted: 02/15/2016] [Indexed: 12/21/2022] Open
Abstract
Tuberculosis involving the central nervous system, a source of considerable morbidity and mortality, forms 5-10% of the disease burden associated with tuberculosis. Central nervous system tuberculosis may present as meningitis, tuberculoma, abscesses, cerebritis or miliary tuberculosis. The most common site of tuberculoma has been reported to be at the grey–white matter junction and the periventricular region. They may even be found in the epidural, subdural and subarachnoid spaces, and the brain stem, with the rarer sites of involvement being the cavernous sinus, sella turcica, hypophysis, hypothalamus, sphenoid sinus and the mastoid air cells. Although tuberculosis is very common in developing countries, with the increasing prevalence of immunosuppression owing to human immunodeficiency virus and patients surviving chemotherapy or organ transplantation, the incidence of tubercular infections has been rising in developed countries. The authors report a case of intracranial tuberculosis in a human immunodeficiency virus-negative patient, who underwent incomplete treatment for tubercular peritonitis and presented with unilateral ptosis. Tuberculous involvement was noted in a racemose pattern in the subarachnoid space, cavernous sinuses, suprasellar cistern and parasellar region. To the best of our knowledge, the term racemose pattern of tuberculoma has not been described before, while about 10 cases of tuberculoma involving the cavernous sinuses have been reported in the literature. Furthermore, the racemose pattern of tuberculosis in the subarachnoid space, as well as involvement of the cavernous sinus, hypothalamus, pituitary and the cisterns, developed paradoxically after initiation of antitubercular chemotherapy.
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Affiliation(s)
| | - Thara Joseph
- Department of Radiodiagnosis, St John's Medical College, Bangalore, India
| | - Arun George
- Department of Radiodiagnosis, St John's Medical College, Bangalore, India
| | - Ravi V Hoisala
- Department of Radiodiagnosis, St John's Medical College, Bangalore, India
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Paradoxical Growth of Optochiasmatic Tuberculoma during the Treatment of Tuberculous Meningitis. CURRENT HEALTH SCIENCES JOURNAL 2014; 40:225-7. [PMID: 25729611 PMCID: PMC4340446 DOI: 10.12865/chsj.40.03.14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 06/10/2014] [Indexed: 11/18/2022]
Abstract
Intracranial brain parenchymal tuberculomas may form paradoxically, days to months after starting antituberculous drug therapy. They may develop in and around optic chiasm and optic nerves after antituberculous treatment as a quite rare occurrence in tuberculous meningitis (TBM) this may lead to severe visual loss if not treated properly. We describe a 5 year-old child with documented TBM being treated with first line antituberculous drugs which developed visual impairment 3 months after starting the treatment. MRI after gadolinium administration revealed multiple perichiasmatic ring enhancing lesions due to tuberculomas. Visual impairment developing in a patient on treatment with antituberculous drugs should give rise to a suspicion of rare optochiasmatic tuberculomas; this necessitates urgent contrast-enhanced MRI of the brain and prompt treatment with steroids.
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Garg RK, Malhotra HS, Kumar N. Paradoxical reaction in HIV negative tuberculous meningitis. J Neurol Sci 2014; 340:26-36. [PMID: 24680563 DOI: 10.1016/j.jns.2014.03.025] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 02/21/2014] [Accepted: 03/12/2014] [Indexed: 01/06/2023]
Abstract
This review focusses on paradoxical reactions occurring during the treatment of tuberculous meningitis (TBM) in human immunodeficiency virus-negative cases. A paradoxical reaction is defined as the worsening of a pre-existing lesion or the appearance of new lesion in a patient whose clinical symptoms initially improved with anti-tuberculosis treatment. A number of different paradoxical reactions have been reported in patients with TBM including expansion of existing cerebral tuberculomas, and appearance of new tuberculomas, hydrocephalus, and optochiasmatic and spinal arachnoiditis. While the exact mechanism of paradoxical reactions is uncertain, an exaggerated immune reaction against Mycobacterium tuberculosis-associated antigens is currently the most accepted theory for tuberculous paradoxical reaction. Corticosteroids are considered to have a beneficial effect in the management of paradoxical reactions. Immuno-modulatory drugs, including tumor necrosis factor-α antagonists, thalidomide and interferon-γ have been used in isolated cases with more severe forms of paradoxical reactions.
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Affiliation(s)
- Ravindra Kumar Garg
- Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India.
| | | | - Neeraj Kumar
- Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India
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Garg RK, Paliwal V, Malhotra HS. Tuberculous optochiasmatic arachnoiditis: a devastating form of tuberculous meningitis. Expert Rev Anti Infect Ther 2012; 9:719-29. [PMID: 21905782 DOI: 10.1586/eri.11.93] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Tuberculous meningitis is primarily a disease of the meninges of brain and spinal cord along with adjacent brain parenchyma. The characteristic pathological changes are meningeal inflammation, basal exudates, vasculitis and hydrocephalus. Tuberculous meningitis has a strong predilection for basal parts of the brain. Exudates, if dominantly present in the interpeduncular, suprasellar and Sylvian cisterns, result in optochiasmatic arachnoiditis and tuberculoma. Optochiasmatic arachnoiditis and tuberculoma are devastating forms of tuberculous meningitis and often associated with profound vision loss. This clinical entity more frequently affects young adults. In a recent study, on the multivariate logistic regression analysis, female sex, younger age and raised cerebrospinal fluid protein content were identified as predictors for developing optochiasmatic arachnoiditis. Frequently, optochiasmatic tuberculoma and optochiasmatic arachnoiditis develop paradoxically while a patient is being treated with anti-TB drugs. MRI reveals confluent enhancing lesions that are present in the interpeduncular fossa, pontine cistern, and the perimesencephalic and suprasellar cisterns. Management of tuberculous optochiasmatic arachnoiditis and optochiasmatic arachnoiditis tuberculoma has been variable. Treatment of optochiasmatic arachnoiditis continues to be a challenge and the response is generally unsatisfactory. In isolated case reports and in small series, corticosteroids, methyl prednisolone, thalidomide and hyaluronidase have been used with variable success. The benefit from neurosurgery is controversial and deterioration may follow the initial temporary improvement. Management of paradoxical optochiasmatic arachnoiditis is also controversial. Some patients regain vision following treatment with anti-TB drugs and continued usage of corticosteroids. Neurosurgery may be considered in the patients with either treatment failure or when diagnosis is in doubt. In conclusion, presence of optochiasmatic arachnoiditis or tuberculoma has important therapeutic and prognostic implications for patients of tuberculous meningitis.
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Affiliation(s)
- Ravindra Kumar Garg
- Department of Neurology, Chhatrapati Shahuji Maharaj Medical University, Uttar Pradesh Lucknow, India.
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Marais S, Pepper DJ, Marais BJ, Török ME. HIV-associated tuberculous meningitis--diagnostic and therapeutic challenges. Tuberculosis (Edinb) 2010; 90:367-74. [PMID: 20880749 DOI: 10.1016/j.tube.2010.08.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Revised: 06/15/2010] [Accepted: 08/29/2010] [Indexed: 10/19/2022]
Abstract
HIV-associated tuberculous meningitis (TBM) poses significant diagnostic and therapeutic challenges and carries a dismal prognosis. In this review, we present the clinical features and management of HIV-associated TBM, and compare this to disease in HIV-uninfected individuals. Although the clinical presentation, laboratory findings and radiological features of TBM are similar in HIV-infected and HIV-uninfected patients, some important differences exist. HIV-infected patients present more frequently with extra-meningeal tuberculosis and systemic features of HIV infection. In HIV-associated TBM, clinical course and outcome are influenced by profound immunosuppression at presentation, emphasising the need for earlier diagnosis of HIV infection and initiation of antiretroviral treatment.
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Affiliation(s)
- Suzaan Marais
- Department of Medicine, GF Jooste Hospital, Manenberg 7764, South Africa.
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Sinha MK, Garg RK, Anuradha HK, Agarwal A, Parihar A, Mandhani PA. Paradoxical vision loss associated with optochiasmatic tuberculoma in tuberculous meningitis: A report of 8 patients. J Infect 2010; 60:458-66. [PMID: 20346972 DOI: 10.1016/j.jinf.2010.03.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Revised: 03/16/2010] [Accepted: 03/19/2010] [Indexed: 11/28/2022]
Affiliation(s)
- Manish Kumar Sinha
- Department of Neurology Chhatrapati Shahuji Maharaj Medical University, Uttar Pradesh, Lucknow, India
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Monga PK, Dhaliwal U. Paradoxical reaction in tubercular meningitis resulting in involvement of optic radiation. Indian J Ophthalmol 2009; 57:139-41. [PMID: 19237788 PMCID: PMC2684430 DOI: 10.4103/0301-4738.45504] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 25-year-old woman was diagnosed to have tubercular meningitis (TBM) with a right parietal infarct. She responded well to four-drug anti-tubercular treatment (ATT), systemic steroids and pyridoxine. Steroids were tapered off in one and a half months; she was put on two-drug ATT after two months. Six months after initial diagnosis she presented with sudden, bilateral visual loss. Vision was 3/200 with afferent pupillary defect and un-recordable field in the right eye; vision was 20/60 in the left eye, pupillary reaction was sluggish and the field showed a temporal hemianopia. On reintroduction of systemic corticosteroids vision improved (20/120 in right eye and 20/30 in left eye) within three days; the field defects improved sequentially to a left homonymous hemianopia, then a left homonymous inferior quadrantonopia. A diagnosis of TBM, on treatment, with bilateral optic neuritis, and right optic radiation involvement was made. Since the patient had been off ethambutol for four months, the optic neuritis and optic radiation lesion were attributed to a paradoxical reaction to tubercular allergen, corroborated by prompt recovery in response to corticosteroids. This is the first report of optic radiation involvement in a paradoxical reaction in neuro-tuberculosis in a young adult.
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Affiliation(s)
- Parveen K Monga
- Department of Ophthalmology, University College of Medical Sciences and GTB Hospital, Delhi-95, India
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Jouvet JC, Thomson V, Granier A, Perpoint T, Berthezène Y. [Answer to march e-quid. Association between balisar and brain involvement: it may be a tuberculosis]. JOURNAL DE RADIOLOGIE 2009; 90:520-522. [PMID: 19503038 DOI: 10.1016/s0221-0363(09)74016-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- J C Jouvet
- Service de Radiologie Hôpital de la Croix Rousse, Lyon
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