Case Presentation: A 65-year-old Vietnamese man presented to the Emergency Department after a scleral defect was noted in his right eye by optometry. He reported four months of floaters and one month of worsening vision and light sensitivity in the right eye. No recent trauma.Ophthalmology exam showed visual acuity of 20/25 in the right eye (OD) and 20/70 in the left eye (OS). Intraocular pressure was 26 mmHg OD, 13 mmHg OS. Slit lamp exam noted a superonasal bluish scleral defect with prolapsed uveal tissue OD. CT sinus/facial revealed multiple calcifications within the brainstem and cerebellum. Subsequent MRI showed diffuse, cerebral ring-enhancing lesions and surrounding vasogenic edema. Chart review revealed the patient was recently hospitalized two months prior for pneumonia and one month prior for epididymitis. He had a 20-pound weight loss since then. He reported pain, headaches, night sweats, nausea, and vomiting. Patient received the BCG vaccine in Vietnam as a child. Initial laboratory workup was largely unremarkable with no infectious markers, negative autoimmune workup, and an unrevealing B-scan.On hospital day two, a CT chest revealed a diffuse miliary pattern of micronodularity throughout the lungs. CT abdomen/pelvis showed calcified granulomas throughout the liver. These findings raised suspicion for disseminated tuberculosis (TB). Lumbar puncture revealed CSF with WBC 24, protein 96, and glucose 46, suggesting a possible TB or fungal source. However, CSF cultures did not isolate an organism. On hospital day 7, empiric treatment was initiated with rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE). A diagnosis of scleromalacia perforans as the presenting symptom of disseminated TB was made. The patient was discharged with outpatient therapy, and his systemic and visual condition continued to improve.
Discussion: Ocular tuberculosis is an uncommon condition, reported in only 1-2% of TB cases in America.1 TB-related scleritis has been documented, with most cases involving the anterior sclera, but it has not been well described. Scleromalacia perforans, or anterior necrotizing scleritis without inflammation, results from a delayed-type III hypersensitivity reaction and can be associated with TB infection.2 A detailed history is crucial to suspect ocular TB. Our patient had several risk factors, including immigrant status from a TB-endemic country, ongoing constitutional symptoms, and recent infections that did not resolve with antibiotics.
Conclusions: Ocular TB, though rare, can be the primary sign of disseminated TB and requires timely diagnosis to prevent vision loss. A reasonable index of suspicion is essential, even with a negative infectious workup. Initial treatment involves a 2-month course of RIPE therapy3, with some cases requiring additional low-dose steroids.4 This case underscores the need to consider ocular TB in patients with unexplained ocular symptoms and risk factors to ensure early intervention and better outcomes.