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Middle East African Journal of Ophthalmology Middle East African Journal of Ophthalmology
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Year : 2021  |  Volume : 28  |  Issue : 2  |  Page : 140-142  

Recurrent tubercular episcleritis

1 Department of Ophthalmology, College of Medicine, King Saud Bin Abdulaziz, University for Health Sciences; Department of Surgery, Division of Ophthalmology, King Abdulaziz Medical City, National Guard-Health Affairs, Riyadh, Saudi Arabia
2 Department of Surgery, Division of Ophthalmology, King Abdulaziz Medical City, National Guard-Health Affairs, Riyadh, Saudi Arabia

Date of Submission28-Jan-2021
Date of Decision07-Apr-2021
Date of Acceptance11-Aug-2021
Date of Web Publication25-Sep-2021

Correspondence Address:

Dr. Muhannad A Alnahdi
College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), P.O. Box 3660, Riyadh 11481
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-9233.326666

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Ocular tuberculosis (TB) is one of the extrapulmonary manifestations of mycobacterium TB. Episcleritis is a rare entity that may affect patients in endemic areas of TB. In this paper, we report a case of presumed recurrent episcleritis attributed to TB. TB should be kept as a possible cause of recurrent simple episcleritis upon encountering patients with endemic backgrounds to prevent the complication sequalae and halt recurrence.

Keywords: Episcleritis, Saudi Arabia, tuberculosis

How to cite this article:
Aldebasi TM, Alasiri AA, Alnahdi MA. Recurrent tubercular episcleritis. Middle East Afr J Ophthalmol 2021;28:140-2

How to cite this URL:
Aldebasi TM, Alasiri AA, Alnahdi MA. Recurrent tubercular episcleritis. Middle East Afr J Ophthalmol [serial online] 2021 [cited 2022 Jun 28];28:140-2. Available from: http://www.meajo.org/text.asp?2021/28/2/140/326666

   Introduction Top

Ocular tuberculosis (TB) is a known presentation that may affect patients with pulmonary TB. TB is considered an endemic disease in multiple countries in Asia like India, Pakistan, and Saudi Arabia.[1] A rare presentation of ocular TB is episcleritis, which may occur in latent or active pulmonary TB. We report a case of recurrent episcleritis that was treated and resolved after anti-tuberculous therapy.

   Case Report Top

A 37-year-old Pakistani male who works as a librarian presented to the outpatient ophthalmology clinic with left eye redness, itchiness, and dull ache for 1 week. His symptoms were recurrent with about four episodes in a year. The right eye was not involved in any of the episodes. He had no history of trauma or ocular surgery. The patient was otherwise clinically free of any other symptoms, and his past medical and surgical history was unremarkable. However, family history was positive for possible exposure to TB as his father was treated for the disease in Pakistan.

Physical examination showed normal visual acuity (20/20), and intraocular pressure of 15mmHg in both eyes. Right eye examination was normal, while left eye examination showed conjunctival injection and engorged episcleral vessels nasally with the absence of any nodular element [Figure 1]. The cornea was clear, the anterior chamber was quiet and pupil reaction was normal and brisk. Iris, lens, and fundus were normal. Systemic examination was unremarkable as well. Routine laboratory tests revealed: hemoglobin was 143 g/L, erythrocyte sedimentation rate was 10 mm/h, total white blood cell count found to be 5.17 × 109/L with the following cell differential: neutrophils 2.08 × 109/L, basophils 0.01 × 109/L, eosinophils 0.20 × 109/L, lymphocytes 2.44 × 109/L, and monocytes 0.44 × 109/L; HIV test and rheumatoid factor were negative. The chest radiograph was negative for any evidence of pulmonary TB. Reminder investigations were within normal limits. Based on the preceding findings, the patient was initially diagnosed with simple episcleritis and treated with topical steroids and oral nonsteroidal anti-inflammatory drugs. On a 1-week follow-up, an improvement was noted subjectively and objectively.
Figure 1: Left eye showing nasal conjunctival and episcleral injection

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Three months later, the patient presented again with a similar episode of conjunctival and episcleral injection in the same eye, therefore, extensive diagnostic workup was obtained to rule out any infectious or rheumatologic etiologies. Results revealed positive serum TB QuantiFERON test and high Purified Protein Derivative (PPD) reading (about 30 mm induration), thus, the infectious disease team was consulted for their evaluation and treatment. The patient was started on four anti-tuberculous medications: Isoniazid, rifampicin, pyrazinamide, and ethambutol for the first 2 months followed by isoniazid and rifampicin for the next 7 months. Follow-up of the patient revealed significant improvement as early as 1 month after treatment initiation. No relapses or recurrences were observed over 12 months of follow-up since completing treatment [Figure 2].
Figure 2: Left eye after completion of anti-tuberculous therapy course showing quiet conjunctiva and episclera

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   Discussion Top

Ocular TB may involve the lids, conjunctiva, cornea, sclera, uveal tract, optic nerve, or the orbit, and it mainly accompanies latent TB wherein the patient is infected with mycobacterium TB but does not have active TB disease.[2],[3] Alorainey et al. studied the incidence of TB in Saudi Arabia and found more than 64 thousand reported cases over 20 years (1991–2010). Of these, 48% were nonSaudis with a 2–3 times higher incidence rate. The majority of nonSaudis were from countries that are known to have high TB endemicity such as India, Pakistan, and Bangladesh.[1] Episcleritis is one rare manifestation of the disease that can present as simple or nodular episcleritis. Simple episcleritis is more common and typically resolves in 2–3 weeks. Nodular episcleritis is more painful, the recurrence rate is more, and it is often associated with systemic diseases such as TB.[4] Our patient was diagnosed with presumed tubercular simple episcleritis of the left eye based on the recurrent nature of the disease, positive PPD, and TB QuantiFERON tests, and his history of possible exposure to an infected relative.

The recent literature had few cases of episcleritis secondary to TB that share a similar presentation pattern, which began by failed initial treatment then thorough history and laboratory investigations led to discovering positive elements pointing towards TB as the probable cause. This was further confirmed by the resolution of the patient's complaints after commencing anti-tuberculous therapy. Episcleral lesions reported in the literature were mostly nodular or otherwise unspecified, and age distribution is rather vast in which cases were reported from 12 to 56 years of age.[5],[6],[7],[8] Our present case differs from them as it presented as a simple sectoral episcleritis and that was not reported in the literature previously. However, the patient shared a similar disease course with complete resolution of the underlying pathology after the treatment.

Despite the idiopathic etiology of episcleritis in most cases, TB serves as a possible cause as shown in this case. We emphasize the need for a high index of suspicion for TB especially with patients of endemic backgrounds. Early diagnosis and treatment of TB, including latent form, in collaboration with an infectious disease specialist, is essential to prevent future recurrences and complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Al-Orainey I, Alhedaithy MA, Alanazi AR, Barry MA, Almajid FM. Tuberculosis incidence trends in Saudi Arabia over 20 years: 1991-2010. Ann Thorac Med 2013;8:148-52.  Back to cited text no. 1
[PUBMED]  [Full text]  
Bramante CT, Talbot EA, Rathinam SR, Stevens R, Zegans ME. Diagnosis of ocular tuberculosis: A role for new testing modalities? Int Ophthalmol Clin 2007;47:45-62.  Back to cited text no. 2
Kurup SK, Chan CC. Mycobacterium-related ocular inflammatory disease: Diagnosis and management. Ann Acad Med Singap 2006;35:203-9.  Back to cited text no. 3
Rosenbaum JJ. The eye and rheumatic diseases. In: Firestein GS, Budd RC, Hans ED Jr., editors. Kelly's Textbook of Rheumatology. 8th ed. Phildelphia: W.B. Saunders Elsevier; 2008.  Back to cited text no. 4
Yadav S, Rawal G. Tubercular nodular episcleritis: A case report. J Clin Diagn Res 2015;9:ND01-2.  Back to cited text no. 5
Kumar P, Kumari D, Shekhar C, Singh R. Rare presentation of nodular episcleritis with tubrculosis: A case report. Int J Contemp Med Res 2016;3:2701-2.  Back to cited text no. 6
Bathula BP, Pappu S, Epari SR, Palaparti JB, Jose J, Ponnamalla PK. Tubercular nodular episcleritis. Indian J Chest Dis Allied Sci 2012;54:135-6.  Back to cited text no. 7
Morita Y, Honda Y, Tanaka H, Abe S. A case suspected of early active pulmonary tuberculosis detected by CT with the onset of episcleritis. Kekkaku 1996;71:519-22.  Back to cited text no. 8


  [Figure 1], [Figure 2]


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