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Show Optochiasmal Tuberculoma Jeanie Paik, MD Rudrani Banik, MD No Relevant Financial Relationships with Commercial Interests #12;Case Presentation Chief Complaint: 48F with complaining of decreased vision OU 2 #12;Case Presentation ▶ ▶ ▶ ▶ 3 Initial presentation in 9/2012 with fever, nausea, vomiting found to have multiple pulmonary nodules and leptomeningeal lesions Diagnosed with miliary TB RIPE (rifampin, isoniazid, pyrazinamide, ethambutol) treatment initiated #12;Case Presentation ▶ ▶ ▶ ▶ ▶ 4 Began having visual problems in November 2012 Ethambutol stopped as a precaution by outside ophthalmologist Course complicated by hydrocephalus, now s/p ventricular shunt Summary: s/p >12 months complete anti TB therapy Presented 12/2013 #12;Case Presentation ▶ Past Medical History ▶ ▶ ▶ ▶ ▶ ▶ ▶ 5 Miliary TB with leptomeningeal lesions Hydrocephalus s/p VP shunt Seizure disorder DM HTN Depression Past Ocular History: None #12;Patient Presentation ▶ Medications ▶ ▶ ▶ ▶ ▶ ▶ ▶ ▶ 6 Isoniazid Rifampin Pyrazinamide Vitamin B6 Amlodipine Levetiracetam Cymbalta Glyburide ▶ Ocular Medications ▶ None ▶ NKDA #12;Patient Presentation ▶ ▶ 7 Family history: Father + glaucoma Social History: Non-contributory #12;Exam 8 OD OS VaCC 20/30 HM Rx -3.75-0.50x107 -3.50sph Pupils Sluggish 5->3 Sluggish 5->3; +APD External Exam EOM full EOM full Lids Wnl Wnl C/S White and quiet White and quiet Cornea Clear, decreased tear break up time Clear, decreased tear break up time AC D/Q D/Q Lens Trace NS Trace NS Ishihara color +test ½ test plate #12;A 9 B #12;A 10 B #12;11 #12;Visual Fields A 12 B #12;Differential Diagnosis ▶ ▶ ▶ ▶ ▶ ▶ 13 Optic nerve/chiasmal lesion VP shunt failure with third ventricular dilation Ethambutol toxicity Nutritional optic neuropathy Infectious ▶ Syphilis ▶ Lyme Inflammatory ▶ Sarcoidosis #12;14 #12;MRI 10/12 15 #12;Optochiasmal Tuberculoma 16 #12;▶ Paradoxical deterioration in tuberculous meningitis is a well recognized phenomenon defined by expansion of an existing tuberculoma or new brain lesions in a pt with symptomatic improvement ▶ Delayed type hypersensitivity response to release of mycobacterial proteins leading to inflammation, edema, expansion ▶ 17 Retrospective review of 8 cases of tuberculous meningitis ▶ good visual acuity and normal visual field at baseline ▶ No tuberculoma at baseline MRI #12;▶ ▶ ▶ ▶ ▶ ▶ 18 All patients were treated with rifampin, isoniazid, pyrazinamide, and streptomycin. No patients received ethambutol. Mean onset of tuberculoma was 41 days after starting treatment (4-8 weeks) All patients received an extended 6 week course of dexamethasone Repeat neuroimaging showed resolution of tuberculoma Vision improved completely in 3 patients, and partially in 3 (2 expired) Not necessarily an indication of drug failure, should not be labeled as drug resistance #12;Discussion: ▶ Causes of vision loss during ATT (anti-TB treatment): ethambutol toxicity, arachnoiditis, hydrocephalus, and tuberculoma ▶ Mechanism of corticosteroids is hypothesized to be reduction in host response rather than improvement of edema ▶ Tuberculoma formation associated with younger age, female sex, and higher protein in CSF ▶ 19 #12;▶ ▶ ▶ 20 3 case series: No tuberculoma on presentation, found to have after starting treatment Given methylprednisolone 500mg IV q12h x 5 days All with improvement in visual fields and vision #12;▶ Ethambutol toxicity: well known, dose-related toxicity ▶ Classically bilateral central or cecocentral defects ▶ 19 cases (38 eyes) of ethambutol toxicity from retrospective review from 1986 to 2010 6 cases (32%) showed bitemporal visual field defects marginating along vertical midline ▶ ▶ None with MRI findings in the chiasmal region ▶ No tuberculoma, infectious chiasmal inflammation, or compressive lesion 21 #12;▶ Ethambutol toxicity: ▶ Deeper retinal layers (abnormal mERG) ▶ Papillomacular nerve fibers (abnormal OCT) ▶ Chiasmal crossing fibers ▶ Prognosis considered to be dependent on degree of nerve injury and degree of co-morbidities at time of presentation ▶ Visual improvement occurred in 17 of 34 eyes (50%), 27 of 34 eyes (79%) visual field improvement (by at least 3 dB) 22 #12;▶ ▶ ▶ ▶ ▶ ▶ Population based study 231 patients with ethambutol optic neuropathy from 2000 to 2008 924 control patients randomly selected (on ethambutol but without neuropathy) Older age, hypertension, renal disease, and ESRD were all risk factors Daily dose of greater than 1200mg was not a significant risk factors compared to two other groups (<800 mg, 800-1199) Limited by lack of data on body weight 23 #12;Back to our patient ▶ ▶ ▶ ▶ ▶ Seen in neuro-ophthalmology clinic S/p >12months RIPE treatment and IV steroids with mild improvement in vision from 2012 presentation. Vcc 20/40, 20/500 Vision stable from initial presentation TSH, T4,T3 wnl, prolactin, GH, estrogen wnl, CBC, BMP wnl MRI 6/4/14 ▶ Resolution of hydrocephalus since 5/21/13 ▶ Improved tuberculoma compared to prior, however signs of active disease (significant abnormal enhancement) ▶ Recommend ID to consider restart TB meds (letter given) because recent MRI findings 24 #12;References 1: Kho RC, Al-Obailan M, Arnold AC. Bitemporal visual field defects in ethambutol-induced optic neuropathy. J Neuroophthalmol. 2011 Jun;31(2):121-6. 2: Joseph M, Mendonca TM, Vasu U, Nithyanandam S, Mathew T. Paradoxical growth of presumed optochiasmatic tuberculomas following medical therapy. JAMA Ophthalmol. 2013 Nov;131(11):1463-7. 3: Wani NA, Khan N, Kosar T, Qayum A. Optochiasmatic tuberculomas: a vision-threatening paradoxical response in tuberculous meningitis. Turk Neurosurg. 2012;22(2):246-9. 4: 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 Jun;60(6):458-66. 5. Chen HY, Lai SW, Muo CH, Chen PC, Wang IJ. Ethambutol-induced optic neuropathy: a nationwide populationbased study from Taiwan. Br J Ophthalmol. 2012 Nov;96(11):1368-71. 25 |
