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Case Report

Presumed tuberculous choroiditis: Unusual

presentation and review of the literature
Aliyu Hamza Balarabe, Jyotirmay Biswas1
Department of Ophthalmology, Federal Medical Centre, Birnin‑Kebbi, Kebbi, Nigeria, 1Department of Uvea and Ocular Pathology,
Sankara Nethralaya, Medical and Vision Research Foundation, Chennai, Tamil Nadu, India

Address for correspondence:

Dr. Aliyu Hamza Balarabe,
Department of Ophthalmology,
Federal Medical Centre, Birnin‑Kebbi,
P. M. B 1126, Kebbi, Nigeria.
E‑mail: hamzabalarabe@yahoo.com
ABSTRACT This is a report of a 35‑year‑old female who was managed as a case of presumed
tuberculous choroiditis. She presented with bilateral serpiginous choroiditis which failed
to heal despite 3 months of combination therapy with steroids and immunosuppressive
medications; however, the lesions successfully healed after initiation of anti‑tuberculous
agents and stoppage of immunosuppressive agents. The association represent underlying
tuberculosis in the aetiopathogenesis of serpiginous choroiditis. This report also highlights
the importance of a detailed systemic and laboratory evaluation of patients presenting with
serpiginous choroiditis.

Key words: Immunosuppression, presumed tuberculous choroiditis, serpiginous choroiditis,

serpiginous‑like choroiditis

INTRODUCTION borders involving the peripapillary area in serpentine pattern.

Serpiginous choroiditis is an inflammation of the retinal
pigment epithelium and choroid.[1] The etiology remains
unknown despite various studies implicating infectious
agents in the pathogenesis.[2‑4] In the middle of 20th century,
tuberculosis (TB) was thought to be the cause; but later, it
was described as serpiginous‑like choroiditis.[5‑7] Bilateral
involvement more commonly in the peripapillary region
with clear vitreous has been the differentiating feature of
serpiginous choroiditis from serpiginous‑like choroiditis,
which is seen more commonly in multifocal arrangement
with significant vitritis.[6,8]
CASE REPORT
A 35‑year‑old female civil servant presented with the complaint
of decreased vision in both eyes since 1‑year duration. She
had been treated elsewhere with oral steroids. Best corrected
visual acuities (BCVA) were 6/9 in both the eyes. Both eyes were
essentially normal on anterior segment examination. Both
eyes revealed quiet anterior chamber and quiet vitreous cavity
with a yellowish area of active choroiditis with geographic
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Fundus fluorescein angiography confirmed the findings.
She was diagnosed as a case of bilateral active peripapillary
serpiginous choroiditis. She was reviewed by an Internist and
was placed on Tab Prednisolone 60 mg/day (1 mg/kg body
weight), Tab Azathioprine 50 mg thrice a day, Tab Cyclosporine
150 mg twice a day, with antacid and calcium supplements.
On regular follow‑up visits initially at monthly interval and
later at 3‑months interval, the choroiditis lesions were
noted to heal in the right eye over a period of 3 months, but
lesions remain active in the left eye with evidence of mild to
moderate vitritis. Further investigations at this time point
revealed positive mantoux test, positive anterior chamber
tap for mycobacterium tuberculosis (MTb) by polymerase
chain reaction, positive quantiFERON TB Gold (QFTB‑G) test
and findings suggestive of TB on High Resolution Computed
Tomographic scan (HRCT) of the chest. Four combination
antituberculous medications were then commenced in
addition to oral steroids while cytotoxic medications were
stopped. The first line anti tuberculous medications were
Ethambutol, Isoniazid, Rifampicin, Pyrazinamide for the first
2 months and subsequently maintained on Ethambutol and
Isoniazid for the subsequent 4 months. Three months after,
the vitritis healed and choroiditis had resolved significantly
and the BCVA in both eyes had improved to 6/6. The patient
was subsequently monitored regularly being co‑managed with
internist for any untoward side effects.

DISCUSSION
DOI:
10.4103/2278-0521.151415 The initial presentation in the index case was with bilateral
active choroiditis in the peripapillary region with clear vitreous

Saudi Journal for Health Sciences - Vol 4, Issue 1, Jan-Apr 2015 79

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Balarabe and Biswas: Tuberculous choroiditis presenting as serpiginous choroiditis
and this has been the differentiating feature of serpiginous
choroiditis from serpiginous‑like choroiditis, which is seen
more commonly in multifocal arrangement with significant
vitritis.[6,8] However, it is important to note that the patient
presented to the referral hospital while on tapering doses of
corticosteroids and this could possibly account for the clear
vitreous at the initial presentation. The lesions were noted
to heal in right eye after 3 months of instituting combination
therapy; however, the lesions in the left eye remain active with
appearance of mild to moderate vitritis which gave a clue to the
possibility of tuberculous choroiditis. Appearance of significant
vitritis and unilateral activity at this time point were more in
keeping with tuberculous serpiginous‑like choroiditis.[6]
In endemic regions like India, management of serpiginous
choroiditis probably starts first with exclusion of ocular
TB, followed by administration of systemic steroids and
immunosuppressive agents.[9] In the present study, there
was no evidence of ocular or systemic features suggestive of
TB at presentation. In a study conducted in eastern India,[9]
Mantoux test was done in all patients that presented with
serpiginous choroiditis and a significant proportion of
the subjects in their series had a positive Mantoux test;
however, since none of the patients with Mantoux test
positivity had any evidence of systemic TB, and none of
them had anterior segment inflammation or vitritis and
all the patients had serpiginous instead of multifocal
arrangement of lesions; antituberculous treatment was not
instituted for the management in their series.[9] Redundancy
of Mantoux test in the management of retinal vasculitis has
been reported in the past, and the same may be applicable
to serpiginous choroiditis.[10,11] Interferon‑gamma assays
has shown promising results in the diagnosis of latent TB
in patients with uveitis.[12] However, it lacks the specificity
to distinguish latent TB from active TB.[8,9] QFTB‑G test was
found to be positive in the index case in addition to positive
serological testing on aqueous tap and evidence of TB on
HRCT chest which was found to be superior to traditional
method of using chest X‑ray as a clue to the diagnosis of
TB.[13] TB is known to be an ocular masquerade and can affect
both anterior and posterior segments.[8] Differentiation
of serpiginous‑like choroiditis, which is a less common
manifestation of ocular TB from serpiginous choroiditis can
pose a diagnostic challenge to the ophthalmologist.[7‑9] This
distinction is more important as the treatment protocol of
the two entity differ, since the former needs antituberculous
treatment, while the later is treated with systemic steroid
and immunosuppressive agents. [9] Serpiginous‑like
choroiditis itself and tuberculous association in patients
with serpiginous choroiditis are presumed to be more
common in endemic regions like India[9] as manifested in
this case and may point to TB as the underlying etiology in
serpiginous choroiditis. Recent studies have demonstrated
an association between serpiginous choroiditis and systemic
TB.[14‑17] The other possibility can be the development of
tuberculous serpiginous‑like choroiditis due to iatrogenic
80 Saudi Journal for Health Sciences - Vol 4, Issue 1, Jan-Apr 2015
immunosuppression since the patient has been on
corticosteroids even before presenting to the referral
hospital, and the later presentation and activity was
unilateral with appearance of vitritis.
The patient had presumed tuberculous choroiditis since
the uveitis was accompanied by evidence of latent TB as
demonstrated by further investigations conducted and
also because no other cause or association of uveitis was
identified after appropriate investigations; additionally
there was a significant resolution of choroiditis within
3 months of instituting antituberculous medications.
Addition of anti‑tubercular therapy to corticosteroids
in uveitis patients with latent or manifest TB has been
reported to significantly reduce the recurrence of uveitis,
aside the resolution of inflammation.[18] Definitive diagnosis
of intraocular TB requires the demonstration of acid‑fast
bacilli (AFBs) or culture of MTb from ocular specimens
and this is extremely rare.[19,20] It is important to exclude
tuberculous etiology before starting immunosuppressive
therapy and doing this requires high index of suspicion
and detailed evaluation. Detailed systemic evaluation of
suspected intraocular TB would require history taking to
include ethnic origin of the patient; history of previous TB
or prolonged contact with TB patient; history of presence of
Human Immunodeficiency Virus or other immunodeficiency
state; presence of constitutional symptoms such as low
grade fever, weight loss, night sweats and presence of
respiratory symptoms such as chronic cough, chest pain and
haemoptysis to exclude active infection.[13] History of other
systemic symptoms is required to exclude extrapulmonary TB;
presence of abnormal physical signs suggestive of TB should
be looked for.[13,21] Presumed ocular TB, however, has been
reported even in the absence of systemic or constitutional
symptoms.[13] Investigations should include determining the
level of inflammatory markers (Erythrocyte Sedimentation
Rate and C‑reactive protein).[13] QFTB‑G test or Tuberculin Skin
Test is needed.[12,22] QFTB‑G has been reported as a significant
tool in the diagnosis of latent TB. It is usually not significantly
affected by previous treatment with systemic steroids or
immunosuppression. A negative QFTB‑G result can be used
as an adjunct before commencement of immunosuppression
in suspected cases of tubercular uveitis in endemic regions
like India.[12] Chest radiograph and HRCT chest should be
conducted to demonstrate evidence of mediastinal or
pulmonary TB. Other investigations required in the diagnosis
of TB, include microscopic examination of specimens for
AFBs; culture of sputum, urine and gastric washout or other
body fluids for detection of MTb. Polymerase chain reaction
for body fluids including aqueous and vitreous humours, and
histology of biopsied tissues including vitreous biopsy in
select cases. It is important to note that ocular involvement
may be the initial manifestation of active TB in patients with
hitherto undetected active TB.[13] In suspected cases, referral
to an internist is appropriate in other to exclude systemic
involvement.
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Balarabe and Biswas: Tuberculous choroiditis presenting as serpiginous choroiditi
CONCLUSION
This report highlights the importance of a detailed ocular,
systemic and laboratory evaluation to exclude TB in patients
presenting with serpiginous choroiditis particularly if there
is delay in clinical response despite appropriate treatment.
ACKNOWLEDGMENT
We appreciate Dr. Vishal K Kulkarni for his assistance and
contributions.
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How to cite this article: Balarabe AH, Biswas J. Presumed tuberculous
choroiditis: Unusual presentation and review of the literature. Saudi J Health
Sci 2015;4:79-81.
Source of Support: Nil, Conflict of Interest: None declared.