A CASE OF INFECTIOUS AND
AUTOIMMUNE DISEASE
COEXISTENCE
Elisabetta Miserocchi MD
Department of Ophthalmology and Visual Sciences
University Hospital San Raffaele, Milan, Italy
CLINICAL CASE
• 36 year old woman, Caucasian
• Occupation: nurse in a nursing home
• Chief Complain 12/2005:
- Loss of vision OD>OS lasting 5 months
PAST OCULAR HISTORY
• 7/05: loss of vision OD>OS
• Previous hospitalization in another
center:
- Diagnosis of bilateral optic disc edema
- Neurologic consult: negative (CT, MRI,
LP)
- Treatment with oral steroids (prn 75 mg)
for 5 months : no visual improvement
EXAMINATION
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VA:
OD: CF
OS: 4/10
Anterior Segment OU: Normal
IOP: 13 mmHg
Fundus:
RETINAL
VASCULITIS
VISUAL FIELD
PAST MEDICAL HISTORY
• 3/05: Pneumonia with blood coughing treated
with systemic antibiotic
• 6/05: Headache, constant and frontal
REVIEW OF SYSTEM
• Obesity
• Hypercholesterolemia
ASSESSMENT
• Bilateral optic neuropathy OD>OS
• Bilateral retinal vasculitis
?
NEW WORK-UP IN OUR
OPHTHALMOLOGY DEPT
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•
•
•
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Chest CT scan: pleural thickening
Brain and orbit MRI: normal
Laboratory tests: HLA-A29 positive
PPD + 50 mm induration
Neurophthalmology consult: presumed
tubercular optic neuropathy
• Infectious disease consult: anti-tubercular
treatment was began
Follow up
• 3/06 visual acuity improvement
OD: 4/10
OS:9/10
• 6/06 Vitriitis OU
• Corticosteroids + CSA added
4/07 Visual acuity restoration
OD: 9/10
OS:10/10
Normal visual field
Late occurrence of
typical
chorio-retinal lesions
FINAL DIAGNOSIS
• Presumed tubercular optic neuropathy
- response to anti-TB treatment alone
- Restoration of visual acuity and visual field
• Birdshot retinochoroidopathy
- Bilateral vitritis, retinal vasculitis, late occurrence of
typical chorioretinal lesions
- Response to corticosteroids treatment
- HLA-A29 +
Our take home message
• Diagnosis of ocular tuberculosis is often
presumptive.
• The absence of clinically evident systemic TB
does not rule out the possibility of ocular TB.
• TB is increasing in Italy in the last 10 years:
PPD test should be tested in all uveitis pts.
• Different pathogenetic mechanisms (infectious
and autoimmune) may coexist and complicate
the clinical spectrum of ocular inflammation.