An Ocular clue for Diagnosis of Tuberculosis

Devaraj, H S,Suresh Babu M, Prasanna Kumar H R, Venkatesh C R,K V K S N Murthy, Sunil,R.

HISTORY
A 35 year old female presented with low grade fever of 20 days and painless reddish lesion in the right eye of 7 days. There was no cough, breathlessness, weight loss, chest pain, haemoptysis, burning micturition, loose stools or vomiting. General Physical examination revealed no abnormality. There was no pallor, icterus, clubbing, cyanosis or lymphadenopathy. Systemic Examination was unremarkable. Ocular Examination revealed a localized non tender nodule with hyperaemia at 70' clock position. Cornea was clear and there was no evidence of iritis. Fundus showed no evidence of choroid tubercles or roth spots.Blood routine showed a normocytic normochromic picture with Eosinophilia (20%), ESR being 30mm/1st hr. Haematological and biochemical parameters were within normal limits. HIV tridot was non reactive and stool microscopy showed no ova/cysts/parasitic forms. With a strong suspicion of Tuberculosis, Mantoux test was performed which showed positivity at 48 hours with 5cm induration. Further investigating with a chest Roentgenogram non homogenous infiltrates were seen involving the left upper zone. Abdominal sonography revealed few enlarged lymph nodes in the Right iliac fossa.












With the above evidence, a diagnosis of Phlyctenular conjunctivitis right eye secondary to disseminated tuberculosis with helminthiasis was made.The patient was initiated on ATT and made a satisfactory recovery and the ocular lesion resolved completely in another 2 weeks time.

DISCUSSION
Phlycten is a characteristic nodular affection of the eye as an allergic response by the conjunctival and corneal epithelium to some endogenous allergens to which they have become sensitised. It is a Type IV hypersensitivity reaction. Most common systemic association is Rosacea2

Causative allergens
? Tubercular proteins in developing countries
? Staphylococcal proteins in developed countries
? Proteins of moraxella axenfield
? Certain helminthic infestations
Stages1
? Stage of Nodule formation
? Stage of Ulceration
? Stage of Granulation
? Stage of Healing

Clinical features
Symptoms-Irritation,mild discomfort in the eye,reflex watering,may be associated with secondy infection

Phlyctenular conjunctivitis -Forms
1. Simple phlyctenular conjunctivitis
Typical pinkish white nodule surrounded by hyperaemia on the bulbar conjunctiva usually near the limbus
2. Necrotising phlyctenular conjunctivitis
Very large nodule with necrosis and ulceration leading to severe purulent conjunctivitis
3. Miliary phlyctenular conjunctivitis
Multiple phlyctens hapazardly arranged or in an annular form around the limbus and may form a ring ulcer
Phlyctenular keratitis
1. Ulcerative Phlyctenular keratitis
? Sacrofulous ulcer-shallow marginal ulcer due to breakdown of a limbal phlycten
? Fascicular ulcer-prominent parallel leash of blood vessels,leaving behind a band shaped opacity
? Miliary ulcer-multiple ulcers scattered over a portion or whole of cornea
2. Diffuse infiltrative Phlyctenular keratitis
Central infiltration of the cornea with characteristic rich vascularization all around the limbus

Differential Diagnosis
? Allergic conjunctivitis
? Episcleritis
? Scleritis
? Inflamed pterygium
? Foreign body Granuloma

COMPLICATIONS
? Secondary infection
? Severe thinning and perforation of globe
? Limbal phlycten can encroach upon the cornea
? Corneal ulcer and scar
TREATMENT
? Treatment of the underlying cause.
? Self limiting in 2-3 weeks
? A short course of topical steroids may accelerate healing
? Antibiotic drops to prevent secondary infection
REFERENCES
1. Kanski Jack J, Clinical ophthalmology, a systematic approach, Elsevier Butterworth Heinemann;2007:275
2. Khurana A K, Ophthalmology, New age international publications,4th Edition,2007:102-104