Orbital and adnexal tuberculosis: a case series from a South Indian population

Isolated tubercular dacryoadenitis in a non-immunocompromised healthy adult

A middle-aged woman presented with a slowly enlarging mass in the right superotemporal orbit and ptosis. The patient had an elevated erythrocyte sedimentation rate, and incisional biopsy showed granulomatous inflammation with Langhan's giant cells suggestive of a tubercular etiology. Tuberculin skin test was negative. The patient responded well to anti-tuberculous therapy. Tubercular dacryoadenitis is a rare presentation of a lacrimal gland mass.

Costal tubercular osteomyelitis presenting as an orbital abscess

Orbital abscesses are most commonly associated with co-existing active paranasal sinus infection. Herein, the authors present the case of an orbital abscess in the setting of costal tubercular osteomyelitis and an anterior chest wall abscess in the absence of any paranasal sinus pathology in an immunocompetent patient. Costal tuberculosis is a very rare form of extrapulmonary skeletal tuberculosis and is challenging to diagnose. Initial presentation as an orbital abscess remote from the site of the primary pathology is of extremely rare occurrence. In this instance, the diagnosis of tuberculous osteomyelitis was suspected primarily on the basis of clinicoradiological features. The patient was treated with, and responded well to, standard first-line anti-tubercular therapy (ATT) for extrapulmonary tuberculosis.

Clinical and laboratory features of PCR-confirmed periocular tuberculosis in China

Experts lack knowledge of periocular tuberculosis (TB) in China. Nested polymerase chain reaction (PCR) shows advantages in diagnosis of extrapulmonary TB. Our study aims to explore the clinical and laboratory features of PCR-confirmed periocular TB. We retrospectively reviewed medical records of presumptive periocular TB and performed nested PCR test to confirm diagnosis. Nine cases were recruited. Clinical symptoms were chronic and insidious. Eight cases achieved favorable visual acuity, while one underwent enucleation due to fungal-TB panophthalmitis. Sensitivity of caseous necrosis, acid-fast bacilli (AFB) staining and interferon γ release assay (T-SPOT) test are 33.3%, 44.4% and 85.7% respectively. Low lymphocyte percentage (P=0.019) and high monocyte-lymphocyte ratio (P=0.042) positively correlate with AFB staining. Male gender (P=0.048) and Langhans giant cell (P=0.048) positively correlate with caseous necrosis. To conclude, traditional TB ancillary tests are not as sensitive as nested PCR technique. Several factors facilitate diagnosis including male gender, decreased lymphocytes, and typical Langhans giant cells.

Orbital tuberculosis: perspectives from Victoria, Australia

PURPOSE

Orbital tuberculosis (TB) is a rare extra-pulmonary manifestation of tuberculosis and its clinical diagnosis poses unique challenges, with potential for destructive complications as well as social and public health implications. The aim of this study is to report our experience of patients presenting with orbital TB and to identify common aspects.

METHODS

A systematic search for mandatory notifications of orbital tuberculosis between January 01, 1994 and December 12, 2016 was undertaken in the Victorian Tuberculosis database. In addition, members of the Australian and New Zealand Society of Ophthalmic Plastic Surgeons (ANZSOPS) were surveyed to identify cases of orbital tuberculosis diagnosed on biopsy in the past 20 years. Medical case notes of identified cases were reviewed retrospectively.

RESULTS

Three cases were identified as having occurred in Victoria, aged 44-59 years old. All cases had emigrated from endemic countries with higher tuberculosis burden. Diagnosis of tuberculosis was often difficult due to few or non-viable acid fast bacilli and low yield of positive culture in paucicellular orbital specimens.

CONCLUSIONS

Orbital TB is rare but remains an important differential diagnosis of orbital mass lesions. The diagnosis of orbital TB requires a high index of clinical suspicion and targeted investigations in patients originating from endemic areas. Diagnosis and treatment rely on effective collaboration between ophthalmologists, infectious disease physicians, and pathologists.

Long-Term Outcomes of Oral Anti-Tubercular Therapy in Patient with Tubercular Dacryoadenitis: A Case Series

Purpose: To describe the clinico-radiological features and long-term outcomes in patients with tubercular dacryoadenitis (TbD) Methods: Retrospective, observational study of TbD patients who underwent a thorough clinical examination, orbital imaging study, and tailored ancillary investigations. Polymerase chain reaction (PCR) and microscopy were done in specific cases. A 4-drug anti-tubercular therapy (ATT) was started and clinical response was monitored in all. Patients with a minimum follow-up of 6 months "off-ATT" were included. Results: All patients were women and three presented with pain, blepharoptosis, and bilateral involvement. In all, ESR was raised, Mantoux test was positive and orbital imaging revealed enlarged lacrimal gland/s. Positive PCR and granulomatous inflammation on microscopy were seen in two patients. At a mean follow-up of 17.25 months, all women responded with no relapse or clinical recurrence. Conclusion: Bilateral lacrimal gland enlargement, positive Mantoux & PCR with early response to ATT may provide sufficient evidence for diagnosing TbD.

[Ocular tuberculosis]

Despite extensive investigations, including the use of Interferon-gamma release assays (IGRA), the diagnosis of intraocular tuberculosis (TB) remains challenging. Ocular evidence of Mycobacterium tuberculosis in low endemic countries for TB is extremely rare, leading mostly to a TB-related ocular inflammation presumptive diagnosis. This present work aims: to highlights the main clinical patterns suggestive of ocular TB; and the latest recommended guidelines for diagnosing ocular TB to clarify interferon-gamma release assay (IGRA) contribution and accuracy to the management of intraocular TB and its diagnosis, in addition to other available diagnostic tools, such as tuberculin skin test, bacteriologic and histologic analysis from intra/extra ocular sample and radiographic investigations; to define the accuracy of these diagnostic tools according to the endemic TB prevalence; and finally to identify therapeutic strategies adapted to the main clinical presentations of ocular TB. Our review of the literature shows that management of suspected ocular TB differs significantly based on whether patients are from high or low TB prevalence countries since accuracy of chest X-ray, tuberculin skin test and IGRA is significantly different. Taking into account these discrepancies, distinct guidelines should be determined for managing patients with suspected ocular TB, taking into consideration home prevalence of TB-patients.

Role of Endoscopic Ultrasound in the Management of Tubercular Uveitis

PURPOSE

To evaluate the role and safety of endoscopic ultrasound-guided fine-needle aspiration cytology (EUS-FNAC) in patients of tubercular uveitis.

DESIGN

Interventional case series Methods: Thirty patients suspected of tubercular uveitis that underwent EUS-FNAC were enrolled in the study. The patient details recorded were age, gender, systemic history, ocular complaints and clinical manifestations. The details of the investigations - skin test, X-Ray chest, CECT (contrast enhanced computed tomography) of chest and findings on EUS-FNAC were also recorded.

RESULTS

Thirty patients with suspected tubercular uveitis showed mediastinal lymphadenopathy on CECT-chest and underwent EUS-FNAC. A total of 27 patients showed tubercular lymphadenitis and three patients showed reactive lymphadenopathy. Ziehl-Neelsen (ZN) staining was positive for acid-fast bacilli in four cases and culture was positive in one case. There were no noted complications of EUS-FNAC.

CONCLUSION

EUS-FNAC is a safe and efficacious procedure for confirming the diagnosis of tubercular uveitis and should be routinely employed wherever available.

The many faces of tuberculosis

Tuberculosis (TB) presenting as multifocal cystic lesions of bone (Jungling's disease) with an intra-orbital mass and calvarial involvement is rare, especially in an immunocompetent host. A 3-year-old boy presented with acute-onset, painless, intra-orbital swelling of the right eye and bony lesions over the right tibia and frontal bone. Tubercular etiology could be established with the help of the Xpert MTB/RIF test, which was performed on pus aspirated from the orbital lesion. The child improved upon antitubercular treatment. Atypical presentations of TB in children are highly variable and might include multifocal osteolytic lesions and intraorbital abscesses. Use of appropriate diagnostic methods, along with timely intervention, leads to a favorable outcome.

Rare presentation of intractable tuberculous panophthalmitis with intraocular and intraorbital abscesses: a case report

Background

We report a rare presentation of extrapulmonary tuberculosis.

Case presentation

A 29-year-old Burmese woman with human immunodeficiency virus infection and known pulmonary tuberculosis who had been treated for 5 months presented to our hospital with unilateral progressive painful visual loss of 1 month’s duration. She was diagnosed with tuberculous panophthalmitis with subretinal and intraorbital abscesses, conjunctival abscess, and extraocular muscle tuberculoma. The diagnosis was confirmed by a conjunctival pus swab with a positive result for acid-fast bacilli and a positive result for a mycobacterial culture. There was high suspicion of multidrug-resistant tuberculosis. Despite receiving ongoing aggressive treatment with conventional antituberculous medications, this patient required subtotal orbital exenteration to control her infection and prevent further progression. Second-line antituberculous medications were added to the first-line therapy, with satisfactory results achieved.

Conclusions

Tuberculous panophthalmitis with intraocular and intraorbital abscesses is a rare presentation of extrapulmonary tuberculosis. Patients who do not respond to first-line antituberculous therapy might be infected with either single-drug or multidrug-resistant Mycobacterium tuberculosis. Patient compliance is one of the key factors that can alter the course of treatment. Careful patient monitoring can improve disease progression, outcome, and prognosis.