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Tuberculosis has re-emerged as a serious public health problem in industrialised countries.1 There are several explanations for the increased incidence but it is mainly due to an increase in immunocompromised hosts such as those who are older or with malignancies, those with AIDS, those who are immunosuppressed after transplantation, and the malnourished. However, a choroidal tuberculoma is rare except in cases with human immunodeficiency virus (HIV) infection.2,3 We present a case of choroidal tuberculoma in an immunocompetent patient with an extrapulmonary tuberculoma in the chest wall, which is also rare.4,5
A 34 year old Filipina woman, who was in good health, complained of a pain in her right lateral chest. Computed tomography scan showed a well defined mass measuring 4 × 4 cm (Fig 1). Cultures of fluid aspirated from the mass showed acid fast bacteria. Polymerase chain reaction demonstrated Mycobacterium tuberculosis DNA in the aspirated fluid. Her sputum had never been positive for tuberculosis. Although the patient had no fever, cough, or anorexia, the mass was diagnosed as extrapulmonary tuberculoma with minimal pulmonary involvement. Anti-tuberculous treatment was started with isoniazid, rifampicin, pyrazinamide, and streptomycin after a 3 month presence of the cold abscess. Two weeks later, she complained of decreased vision in her left eye.
On initial examination, the best corrected visual acuities were 30/20 in the right eye and 80/200 in the left eye. Anterior segment examination was unremarkable, and no evidence of anterior or posterior inflammation was present.
Fundus examination showed an elevated yellow-white mass in the left eye that measured approximately 2 × 2 disc diameters just inferior and temporal to the optic disc (Fig 2A). The mass had a slightly irregular and fuzzy outline, and the disc had irregular margins and was reddish. There was a flat retinal detachment in the macula area, and fluorescein angiography (FA) demonstrated minimal early fluorescence with late moderate hyperfluorescence and peripapillary leakage in the lesion (Fig 2B). Indocyanine green angiography (IA) demonstrated persistent blockage of fluorescein (Fig 2C). Optic coherence tomography (OCT) showed a highly elevated mass associated with a serous retinal detachment. We excluded sarcoidosis, toxoplasmosis, or fungus infection by laboratory examinations; the levels of angiotensin converting enzyme, β-d-glucan, titre of antibody for toxoplasmosis, and metastatic tumour from a breast cancer. HIV infection was also ruled out.
The visual acuity in the left eye decreased to 12/200 because of the retinal detachment, and vitreous cells and opacities, and retinal vasculitis were observed. Four to 6 weeks after beginning the anti-tuberculosis therapy, the mass became smaller and visual acuity improved. Although retinal folds were present in the macular lesion after 16 weeks of therapy, the best visual acuity was 20/20 (Fig 3). The cold abscess in the chest wall disappeared within 2 months, with drainage of the fluid and injection of streptomycin.
There are only a few reported cases of solitary choroidal tuberculoma,1–3 and it may present with or without active pulmonary tuberculosis. Ocular tuberculosis commonly presents in the choroid, and reaches the choroid by direct haemotogenous spread from a primary infection.1 The chest wall is also a rare site for tuberculosis,4 and the co-occurrence of chest wall tuberculosis and choroidal tuberculoma has never been reported with or without HIV infection.1–5 Rib tuberculosis was observed in 5% of all cases of bone and joint tuberculosis, and only in 0.1% of all hospital admission for tuberculosis.4 It is usually secondary to haematogenous spread or, more rarely, due to direct extension of underlying pleural or pulmonary parenchymal disease.5 In our patient, minimal pulmonary involvement was suspected in the apical lesion, not in chest wall mass lesion. Taken together, the tuberculomas in this patient may be caused by direct haematogenous dissemination. Antituberculosis therapy was effective for both tuberculomas.
In conclusion, we report a rare case of choroidal tuberculoma with chest wall tuberculosis. With the re-emergence of tuberculosis, ophthalmologists should be aware that solitary choroidal tuberculoma as well as extrapulmonary tuberculosis can occur in immunocompetent individuals.