West London experience of presumed ocular tuberculosis (2012-2017): Ocular features, systemic investigations and approaches to treatment

Session Details

Session Title: Free Paper Session 10: Uveitis

Session Date/Time: Friday 08/09/2017 | 11:00-12:30

Paper Time: 11:36

Venue: Room 111

First Author: : C.Sethi UK

Co Author(s): :    G. Russell   M. Stanford                          

Abstract Details

Purpose:

London may be regarded as the European capital of Tuberculosis (TB), with incidence in some boroughs approaching 150 cases per 100,000. Numbers are increasing as a result of rising multi-drug resistant TB, HIV infection and global migration. Intra-ocular sampling for microscopy, culture or polymerase chain reaction is not routinely undertaken in these patients. Presumed Ocular TB (POTB) therefore remains a clinical diagnosis, with indicative ocular signs, immunological evidence of prior TB exposure and possible evidence of pulmonary or extra-pulmonary TB foci. We describe the clinical phenotype, systemic investigations and treatment of POTB patients presenting over a 5-year period.

Setting:

1. Western Eye Hospital, Imperial College Healthcare NHS Trust, London, UK 2. Department of Respiratory Medicine, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK Ophthalmic assessment and management was conducted at the Western Eye Hospital, with referral to and from the TB Service at St Mary's Hospital.

Methods:

A retrospective survey of POTB patients presenting to the Uveitis Service at the Western Eye Hospital (WEH) over a 5-year period. Patients were identified from communication letters between the WEH and the TB Service at St Mary's Hospital and from the London TB Register, where ocular pathology is recorded as a possible extra-pulmonary manifestation of TB in patients undergoing anti-tuberculous therapy (ATT). All POTB patients referred for TB screening received a Tuberculin Skin Test (TST), T-SPOT interferon-gamma release assay (IGRA) and chest x-ray (CXR). Sputum specimens were not taken, in the absence of respiratory symptoms. Patients were then referred to the TB Medical Clinic to look for foci of active TB. If the CXR was abnormal, a thoracic computerised tomography (CT) scan was conducted, with subsequent endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of enlarged mediastinal lymph nodes. Fluorodeoxyglucose positron emission tomography (FDG-PET) was employed to detect nodal activity in the absence of an obvious pulmonary focus on chest imaging. Active extra-pulmonary lymph nodes were biopsied for histology, acid-fast bacilli (AFB) staining and culture. The type and duration of ATT was guided by the results of these investigations and the ophthalmic presentation, supplemented with topical, peri-ocular or systemic immunosuppression, as required.

Results:

Summary data for 30 patients is presented. The male:female sex ratio was equal with an age range of 25-73 (mean 41). Only 3 were UK nationals. Other patients were relatively recent immigrants from the Indian Subcontinent (17); African countries (7) and Eastern Europe (3). None of them had constitutional or respiratory symptoms suggestive of TB. All had positive TST and IGRA results. The CXR was abnormal (but not diagnostic of TB) in 10 patients and a thoracic CT scan was conducted in 15 and abnormal in 8 (nodes, nodules, interstitial lung disease). EBUS-TBNA was performed in 13 patients. FDG-PET scans in 18 patients detected positive nodal uptake in 12, comprising thoracic, pancreatic, axillary, cervical and inguinal lymph nodes. Although there was some histopathology suggestive of TB in a few EBUS-TBNA and lymph node biopsy samples, these all proved negative for AFB staining and mycobacterial culture. Clinical presentations included intermediate uveitis (8), panuveitis (6), serpiginous-like (4), multifocal (3) or unifocal (2) choroiditis, retinal vasculitis (6) and one case of granulomatous anterior uveitis, with bilateral ocular pathology in 20 patients. Duration of ATT varied from 6-12 months and steroid therapy was used topically (14), systemically (10), peri-ocularly (10) and intra-vitreally (4).

Conclusions:

The incidence of POTB in patients infected with TB varies from 1-4% in low endemicity countries, to greater than 10% in high endemicity countries. Some London boroughs have become 'endemicised' for TB due to migrant populations. We have a higher diagnostic suspicion of POTB in recent immigrants from the Indian Subcontinent, Africa and Eastern Europe. Often, they are of working age and present with bilateral ocular involvement. Common clinical phenotypes include intermediate uveitis, panuveitis, choroiditis and retinal vasculitis. Serpiginous-like choroiditis (which we refer to as 'ampiginous') appears to be particularly indicative of POTB. Our patients had no systemic symptoms, but investigations did reveal some pulmonary and extra-pulmonary foci suggestive of active TB, prompting quadruple ATT for 3 months (Rifampicin, Isoniazid, Pyrazinamide, Moxifloxacin), followed by dual ATT (Rifampicin, Isoniazid) for 6 months. Patients with a lower diagnostic suspicion of POTB received dual ATT for 6 months. We designate POTB with retino-choroidal involvement (retinal vasculitis, choroiditis) as 'active OTB'. These patients respond well to ATT and immunosuppression, usually achieving a burnt-out, quiescent ocular disease state. POTB with predominantly intermediate or panuveitis can be more insidious, requiring chronic treatment and management of cystoid macular oedema. We refer to this as 'reactive OTB'.

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