Primary Conjunctival Tuberculosis-2

Case Report
PRIMARY CONJUNCTIVAL TUBERCULOSIS IN A 14 YEAR OLD GIRL
Jeyanth Suresh Rose1, Anupriya Arthur1, Renu Raju2 and Meera Thomas3
(Received on 9.2.2010; Accepted after revision on 2.12.2010)
Summary: Tuberculosis is a common disease in India. However, tuberculosis primarily affecting the conjuctiva is a rare
entity. We report a 14-year-old girl who presented with unilateral eye discharge, watering, redness and itching for two
weeks. Giant papillae were present on the upper tarsal conjunctiva. A provisional diagnosis of allergic conjunctivitis was
made. Topical therapy with 1% Prednisolone acetate and 2% Sodium cromoglycate was commenced. The patient returned
six months later with no improvement in the symptoms.The tarsal conjunctiva had a polypoidal, velvety appearance with
giant papillae. A fibrinous membrane was seen over the tarsal conjunctiva and a preauricular node was found. Excision biopsy
and histopathologic examination revealed necrotizing granulomatous inflammation suggestive of tuberculosis. Systemic
examination and investigations were normal. She was started on anti-tuberculous therapy. In two months she showed
complete resolution of symptoms and marked reduction in papillae and conjunctival thickening.
Symptoms and signs of unilateral conjunctivitis may masquerade as primary conjunctival tuberculosis. In an
endemic country like India, laterality, chronicity and non-resolution of symptoms with steroids are indications for pursuing
a biopsy earlier than later. In our patient, the histopathology clinched the diagnosis of conjunctival tuberculosis resulting
in a faster and complete resolution of the disease condition. [Indian J Tuberc 2011; 58: 32-34]
Key words: Conjunctival. Tuberculosis, Histopathology.
INTRODUCTION CASE REPORT
Tuberculosis (TB) is a major cause of A 14-year-old school girl presented to a

illness world-wide. Globally 9.2 million new cases tertiary multispecialty teaching hospital in October
and 1.7 million deaths occurred because of 2005 with discharge, watering, redness and itching
tuberculosis worldwide.1 TB is a systemic disease of the left eye for two months. She had no prior
that commonly affects the lung. Tuberculous medical illness or eye disease and had never used
involvement in the eye has been reported.2-7 Most contact lenses. She had no past or family history of
patients with ocular TB have no systemic tuberculosis. On examination, her left eyelid was
manifestations of the disease 2,3 We report a girl who thickened. There was minimal discharge with a
presented with a chronic unilateral conjunctivitis, mechanical ptosis and giant papillae on the upper
who was treated empirically for allergic tarsal conjunctiva. There were no limbal papillae or
conjunctivitis. Due to non-resolution of signs and Horner Trantas spots. The cornea was clear, the
symptoms, histopathology was pursued. The biopsy anterior chamber had no cells or flare. The intraocular
report and the therapeutic response to Anti pressure was 16 mm of Hg. The posterior segment
Tuberculous Therapy confirmed the diagnosis of was normal. The fellow eye examination was
conjunctival tuberculosis in this patient. In areas normal. Besides the eye findings in the left eye, the
endemic for tuberculosis, considering TB in the remaining physical examination was normal. A
diagnostic algorithm of non-resolving unilateral provisional diagnosis of allergic conjunctivitis was
conjunctivitis would be worthwhile. made. Topical therapy with 1% Prednisolone acetate
1. Assistant Professor 2. Professor 3. Associate Professor

Schell Eye Hospital, Christian Medical College, Vellore.
Correspondence: Dr. Jeyanth Rose, Assistant Professor, Schell Eye Hospital, Arni Road, Christian Medical College & Hospital,
Vellore-632 001 (Tamil Nadu) E-mail: jeyanthrose@hotmail.com; Ph: 0416-2281205, 09840185213 (Mobile)
Indian Journal of Tuberculosis

JEYANTH SURESH ROSE ET AL 33
Fig.1: Giant papillae extending upto the lid margin Fig. 2: Giant papillae with fibrinous membrane
of the upper lid. over the upper tarsal conjunctiva.
and 2% Sodium cromoglycate was commenced. The TREATMENT
patient returned six months later with no
improvement in the symptoms. The tarsal The patient was started on Anti-tuberculous
conjunctiva had a polypoidal velvety appearance and therapy according to current guidelines for the
papillae were seen extending up to the upper lid margin treatment of tuberculosis by the DOTS (Directly
(Fig. 1). A fibrinous membrane was seen over the Observed Therapy Shortcourse).
conjunctiva (Fig. 2). There was one enlarged pre-
auricular node. BCG scar was seen on the left arm. Isoniazid, Rifampicin, Ethambutol,
Histopathology examination showed necrotizing Pyraziamide were prescribed for two months
granulomatous inflammation suggestive of followed by Isoniazid and Rifampicin for four
tuberculosis (Fig. 3). Following this, a conjunctival months. There was no evidence of ocular toxicity
scraping was sent for Acid Fast Bacilli culture and with the above medication.
fungal culture which were negative. Chest X-ray
and ESR were normal, Mantoux was 12x10mm. Her In two months, the patient showed complete
HIV test was negative. resolution of symptoms and marked reduction in
papillae and conjunctival thickening (Fig. 4).
Fig. 3: Histopathology - H & E stain-conjunctival Fig. 4: Upper tarsal conjunctival after two months
biopsy with granuloma. of ATT.

34z PRIMARY CONJUNCTIVAL TUBERCULOSIS IN A 14-YEAR OLD GIRL
DISCUSSION A red eye with itching and irritation is a

common presentation of varied aetiologies. Detailed
In current clinical practice, the incidence clinical assessment is imperative and often guides
of active tuberculous lesions of the conjunctiva are treatment in clinical practice. In the event of non-
so rare that the physicians index of suspicion is resolution of symptoms, close follow up and a tissue
very low. Variations in the clinical picture depend diagnosis are important and must be sought. In our
on the immunoallergic state of the patient.2 The patient, the histopathology clinched the diagnosis
morphological characteristics of conjunctival lesions of conjunctival tuberculosis. Appropriate treatment
fall into 4 groups3: was initiated and resulted in complete cure. In areas
endemic for infectious disease (e.g.TB), the
1. Ulcerative- Localized ulceration associated threshold for pursuing histopathology should be
with lymphadenopathy. low. This approach could be eye saving as
2. Nodular- Localized area of conjunctivitis definitive treatments are available.
containing multiple nodules that later
ulcerate.5 REFERENCES
3. Hypertrophic granulomatous Massive
flattened granulations commonly associated 1. WHO.Global tuberculosis control:a short update to the
with lymphadenopathy. This is the most 2009 report http//www.who.int/tb/publications/
global_report/2009/en/index.html
common type. 2. Sollom AW Primary conjunctival tuberculosis. British
4. Pedunculated- Pedunculated mass without Journal of ophthalmology 1967; 51: 685.
lymphadenopathy. 3. Archer D, Bird A, Primary Conjunctival Tuberculosis.
British Journal of ophthalmology 1967; 51: 679-684.
4. Kamel S, Primary tuberculosis of the conjunctiva. British
This patient had features suggestive of Journal of ophthalmology 1950; 34: 322-7.
hypertrophic granulomatous type. The chronic 5. Tulvatana W, Sansopha L, Pisarnkorskulp, Primary
nature of the symptoms and its refractory nature to conjunctival tuberculoma: A case report. Journal of Med
therapy suggested the possibility of malignancy or Assoc Thai 2001; 84: 127-30.
6. Jennings A, Bilous M, Asimakis P, Maloof AJ,
chronic infection. A conjunctival squamous cell Mycobacterium tuberculosis presenting as chronic red eye.
carcinoma was a remote clinical consideration but Cornea 2006 Oct;25(9):1118-20
the patients age group made it less likely (peak 7. Biswas J, Kumar SK, Rupauliha P, Misra S, Bharadwaj I,
prevalence at 60 years).8,9 Therese L, Detection of Mycobacterium tuberculosis by
nested Polymerase Chain Reaction in a case of
subconjunctival tuberculosis Cornea 2002 Jan;21(1):123-
Though this case is not culture proven, the 5..
histopathological correlation and the therapeutic 8. Lee G A, Hirst L W, Ocular surface squamous neoplasia.
response to anti-tuberculous therapy clearly establish Survey ophthalmology 1995; 39: 429-50.
the diagnosis which could have been established 9. Lee G A, Hirst L W, Retrospective study of ocular surface
neoplasia. Australia New Zealand Journal of
earlier had there been a higher index of suspicion. ophthalmology 1997; 25:269-76.

Primary Conjunctival Tuberculosis-2

Uploaded by

Copyright:

Available Formats

Primary Conjunctival Tuberculosis-2

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Primary Conjunctival Tuberculosis-2

Uploaded by

Copyright:

Available Formats

Case Report

PRIMARY CONJUNCTIVAL TUBERCULOSIS IN A 14 YEAR OLD GIRL

(Received on 9.2.2010; Accepted after revision on 2.12.2010)

Key words: Conjunctival. Tuberculosis, Histopathology.

INTRODUCTION CASE REPORT

Tuberculosis (TB) is a major cause of A 14-year-old school girl presented to a

1. Assistant Professor 2. Professor 3. Associate Professor

Indian Journal of Tuberculosis

Indian Journal of Tuberculosis

DISCUSSION A red eye with itching and irritation is a

Indian Journal of Tuberculosis

You might also like