Journal of Neuro-Ophthalmology, September 1999, Volume 19, Issue 3

Tuberculous Neuroretinitis

OBJECTIVES: To describe a patient with tuberculous neuroretinitis. MATERIALS AND METHODS: Retrospective case report. RESULTS: We describe a 43-year-old otherwise asymptomatic woman with a known exposure to tuberculosis who had unilateral optic disc edema and a partial macular star (neuroretinitis). This was followed approximately 1 year later by the development of an exudative retinal detachment in the setting of bilateral multifocal choroiditis. Laboratory testing revealed a marked positive cutaneous reaction to purified protein derivative (PPD). Treatment with antituberculosis medicine alone resulted in prompt resolution of the choroidal infiltrates and complete flattening of the exudative detachment. CONCLUSIONS: Tuberculosis should be considered in the differential diagnosis for patients with neuroretinitis.

Journal of Neiiiv- Oi> litlialmolof> y 19( 3): 201- 204, 1999. 0 1999 Lippincotl Williams & Wilkins, Inc., Philadel|) hia Tuberculous Neuroretinitis Stephen U. Stechschulte, MD,* f Robert Y. Kim, MD, f and Emmett T. Cunningham, Jr., MD, PhD, MPH*| Objectives: To describe a patient with tuberculous neuroretini­tis. Materials and Methods: Retrospective case report. Results: We describe a 43- year- old otherwise asymptomatic woman with a known exposure to tuberculosis who had uni­lateral optic disc edema and a partial macular star ( neuroretini­tis). This was followed approximately 1 year later by the de­velopment of an exudative retinal detachment in the setting of bilateral multifocal choroiditis. Laboratory testing revealed a marked positive cutaneous reaction to purified protein deriva­tive ( PPD). Treatment with antituberculosis medicine alone re­sulted in prompt resolution of the choroidal infiltrates and com­plete flattening of the exudative detachment. Conclusions: Tuberculosis should be considered in the differ­ential diagnosis for patients with neuroretinitis. Key Words: Choroiditis- Exudative retinal detachment- Optic disc edema- Macular star- Serous retinal detachment- Tuberculosis. Neuroretinitis is a clinically unique form of optic neu­ropathy characterized by optic disc edema in the pres­ence of peripapillary and macular subretinal and in-traretinal exudates, often forming a complete or partial macular star ( 1- 3). Vitreous inflammation is typically mild. Most cases are unilateral, and an afferent pupillary defect is frequently present. Recurrences, although un­common, can occur ( 4). Organisms reported to cause neuroretinitis include Bartonella henselae ( 5- 10), Treponema pallidum ( 11- 14), Toxoplasma gondii ( 15- 17), Toxocara canis ( 18,19) Borrelia burgdorferi ( 20), Leptospira ( 1), and para­myxovirus ( 21). Rarely, patients with Mycobacterium tu- /? e/ x'M/ o. y « - associated optic disc edema and retinal exu­dates have been described ( 22), but only in the setting of large peripapillary choroidal lesions ( 23,24). We de­scribe a patient with evidence of systemic M. tuberculo­sis infection who initially had isolated neuroretinitis. CASE REPORT A 43- year- old woman, a Mexican immigrant, com­plained of shadows in her right eye for 2 months. The ocular history was unremarkable. Medical history was significant for exposure to a child at home who had been treated for pulmonary tuberculosis. Review of sys­tems was otherwise noncontributory. Best- corrected vi­sual acuity was 20/ 30 on the right and 20/ 20 on the left. No afferent pupillary defect was present. Intraocular pressure was normal. Examination of the left eye was unremarkable. Examination of the right eye revealed moderate optic disc edema and subretinal exudates forming a partial macular star ( Fig. 1). Syphilis serolo­gies, angiotensin- converting enzyme level, and a chest radiograph were negative. The patient was lost to fol­low- up, but returned 13 months later complaining of decreased vision in the left eye. Best- corrected visual acuity was 20/ 25 on the right and 20/ 200 on the left. No afferent pupillary defect was present. Fundus examina­tion revealed mild vitreous inflammation, moderate op­tic disc edema, and multifocal choroiditis in each eye ( Figs. 2A & B). A localized exudative retinal detach­ment involving the fovea was present on the left ( Fig. 2B- D). Purified protein derivative ( PPD) skin testing produced 15 mm of induration with overlying dcrma-tolysis ( Fig. 3). A repeat chest radiograph was nega­tive. Examination of the cerebrospinal fluid was nor­mal. Treatment with systemic isoniazide and rifampin resulted in prompt resolution of the choroidal infil­trates and complete flattening of the exudative retinal detachment within 3 months. No corticosteroids were given. Visual acuity at last follow- up was 20/ 25 in each eye. DISCUSSION From * The Francis I. Proctor Foundation and iThe Department of Ophthalmology, University of California San Francisco, School of Medicine, San Francisco, CA 94143- 0944. Address correspondence and reprint requests to Dr. Emmett T. Cun­ningham, Jr., The Pearl & Samuel J. Kimura Ocular Immunology Laboratory, The Francis I. Proctor Foundation, University of California San Francisco, School of Medicine, San Francisco, CA 94143- 0944. M. tuberculosis is an infrequent but well- recognized ocular pathogen ( 22). Tuberculous optic neuropathy is one of the best described complication of systemic infection and is almost always retrobulbar and usually observed as a complication of tuberculous menin­gitis ( 25,26). In contrast, anterior optic neuropathy caused by tuberculosis is rare and usually appears as a 202 STECHSCHULTE ET AL. FIG. 1. A photograph of the right fundus at initial presentation reveals neuroretinitis, characterized by moderate optic disc edema with subretinal exudates in a partial macular star pattern. consequence of adjacent or nearby choroiditis ( 23, 24). Our patient was unique in that her neuroretini­tis initially occurred in isolation. Our patient was also noteworthy in that she developed a localized exuda­tive retinal detachment over an area of tuberculous cho­roiditis, an uncommon but reported cause of serous el­evation of the retina in patients with uveitis ( 24,27, 28). The diagnosis of ocular tuberculosis is often difficult ( 22). Histopathologic or culture identification of acid-fast bacilli from ocular biopsy specimens offers the strongest evidence for infection ( 28,29- 32), but is usu­ally reserved for severely damaged or end- stage eyes. Polymerase chain reaction- based amplification of M. tuberculosis- specific DNA sequences from ocular fluid specimens provides an alternative ( 32- 35) and, perhaps less risky, technique for identifying infection, but is not widely available and has yet to be standardized with regard to sensitivity or specificity. In the absence of such direct identification of M. tuberculosis or its DNA from ocular tissues, the diagnosis of ocular tuberculosis re­mains presumptive and is based on clinical evidence of concurrent or past pulmonary or extrapulmonary in­fection. Findings in support of the diagnosis of ocular tuberculosis can include a positive chest radiograph or sputum sample, a positive PPD ( particularly when > 15 mm), a positive urine, blood, synovial or cerebrospinal fluid culture, a positive biopsy of a suspicious extra­ocular tissue site, or clinical improvement in response to antituberculous therapy. We chose not to perform an ocular biopsy or fluid aspirate in our patient given our strong suspicion of tuberculosis based on her known history of exposure to tuberculosis, on her markedly positive PPD, and on her prompt and complete response to antituberculosis medications without the use of lo­cal or systemic corticosteroid therapy. Although the chest radiograph was negative in our case, similar pa­tients with ocular tuberculosis and a positive PPD but negative chest radiograph have been described ( 23, 28,36). Ocular tuberculosis can even occur in the com­plete absence of detectable systemic infection ( 29,30, 34). In summary, M. tuberculosis infection can cause neu­roretinitis and should be considered in any patients with systemic signs or symptoms suggesting tuberculosis, with a known exposure to other tuberculosis, or who come from or have traveled to areas where tuberculosis is endemic. .1 Nniw- Ophllmlnwl, Vol. 19. No. .1 1999 TUBERCULOUS NEUR0RETIN1T1S 203 FIG. 2. 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