Brief Communication
 
Multisystem Tuberculosis - Total Ophthalmoplegia as an Initial Presentation
 
Karishma Goyal, Sandeep Parwal, Kamlesh Khilnani
Department of Ophthalmology, SMS Medical College, Jaipur, Rajasthan, India


Corresponding Author
:
Karishma Goyal
MS, DNB
B-21, Vaishali Nagar, 
Jaipur, Rajasthan - 302021
India
Email id: drkarishma54@gmail.com


Abstract

Caseating granulomas are the pathological hallmark of tuberculosis and the causative organism is Mycobacterium Tuberculosis. We report a subject who presented initially with total ophthalmoplegia and choroiditis. Imaging showed vascular infarcts in brain and Pott’s spine. This specific case highlights the involvement of three different extrapulmonary systems without obvious pulmonary tuberculosis. A detailed examination should be done for each and every complaint of a patient having a suspicion of tuberculosis, to aid in early diagnosis of the disease.

Introduction
Tuberculosis (TB) is a contagious infection that can involve various organ systems and have a variable clinical presentation.1 Despite pulmonary form being the most common, tuberculosis can also involve extrapulmonary systems via hematogenous spread, direct inoculation or hypersensitivity reactions. Tubercular meningitis (TBM) has a wide spectrum of presentation, among those, cranial nerve palsies are common and can manifest as neuro-ophthalmic involvement including third nerve palsy, pupil abnormalities, disc changes eg papillitis, papilledema, or optic atrophy and choroidal tubercles.2 Early diagnosis and treatment are strongly related to the rate and extent of recovery. Herein, we describe a rare case with constellation of CNS, ocular and skeletal associations of tuberculosis. To the best of our knowledge, no previous report exists on such a presentation in a single case.

Case Report
A 25-year-old female presented in ophthalmology OPD with complaints of right eyelid drooping and diplopia since 3 days. The right pupil was midilated & fixed and there was restriction of all extraocular movements. Although the left pupil was round, regular & reacting, there was limitation of abduction (Figure 1). Her best corrected visual acuity in right eye (RE) was LOGMAR 0.0 and it was 0.3 in the left eye (LE). The posterior segment had a subretinal yellowish elevated lesion of 1 disc diameter just below the superior arcade in the LE. The RE was normal. On fundus fluorescence angiography (FFA), there was a localized area of hyperfluorescence secondary to pooling of the dye in the late phase (Figure 2). Hematological investigations, chest X-ray, Human Immunodeficiency Virus (HIV) tridot and Treponemal Pallidum Hemagglutinin Assay (TPHA) were normal. Mantoux test was positive (15 mm induration). PCR of vitreous biopsy was positive for tubercular antigen. The patient was also complaining of backache since 4 months for which orthopedics opinion was taken. MRI brain with contrast and diffusion-weighted imaging (DWI) revealed dilatation of bilateral ventricles & vasculitic infarcts in the left periventricular location, left capsuloganglionic region, right frontal region and bilateral centrum semiovale. On MRI screening of dorsal spine, there was paravertebral contrast enhancement around D9-D11 vertebrae suggestive of Pott’s spine (Figure 3 & 4). Confirming the diagnosis of tuberculosis, intensive phase of Anti Tubercular Treatment (ATT) was started.






Discussion
Tuberculosis can involve various organs at the same time and so manifest variably. The present case shows a wide range of the diversity and rarity of the initial manifestations in TB meningitis as there was absence of common signs and symptoms like headache, neck stiffness, malaise etc. Therefore, we should always consider TBM as a common differential diagnosis when there is an abrupt deficit of 3rd or 6th cranial nerve.3
The prevalence of ocular TB is from 4% to 10.5%.4 Various ophthalmic pathologies related to TB have been reported in literature including keratoconjunctivitis, third or sixth nerve palsies, choroidal tuberculoma, choroiditis, homonymous hemianopia, and nystagmus. Among these, choroidal tuberculoma is the most common ocular manifestation.5 Neuro-ophthalmic manifestations like isolated or multiple cranial nerve palsies, are suggestive of primary CNS involvement.6
According to Komolafe et al, TBM is associated with deposition of some gelatinous material at the base of the brain leading to cerebral vasculitis or CSF pathway blockage (hydrocephalus) or entrapment of cranial nerves.7 Because of the long course of oculomotor nerve and abducent nerve in the base of the brain, their involvement is common in tubercular meningitis. The sixth cranial nerve is usually primarily and the most frequently affected.8
About 10% of extrapulmonary tuberculosis shows skeletal involvement, and among these, the spine is involved in almost 50% cases. In endemic countries, older children or young adults are mainly affected in spinal TB, but it is more prevalent in older adults in developed countries. Among the wide range of symptoms; back pain is the most frequent and others are malaise, night sweats, weight loss, and neurologic signs.9 MRI identifies not only bone destruction but also soft tissue pathology like granulomas and tuberculomas, hence considered more effective than plain radiographs or CT.10
Being a part of the endemic country, tuberculosis as a common differential should always be kept in mind as early diagnosis is an essential part of treatment of tubercular meningitis. 

References
  1. Avasthi R, Mohanty D, Chaudhary SC, Mishra K. Disseminated tuberculosis: interesting hematological observations. J Assoc Physicians India 2010; 58:243-4.
  2. Desai HG, Anklesaria ED. Ophthalmological aspects of tuberculous meningitis. J Indian Med Assoc. 1967; 49:429-32.
  3. Thwaites GE, Chau TT, Stepniewska K, Phu NH, Chuong LV, Sinh DX, et al. Diagnosis of adult tuberculous meningitis by use of clinical and laboratory features. Lancet 2002; 360:1287 92.
  4. Wakabayashi T, Morimura Y, Miyamoto Y, Okada AA. Changing Patterns of Intraocular Inflammatory Disease in Japan. Ocul Immunol Inflamm 2003; 11:277-86.
  5. Milla E, Zografos L, Piguet B. Bilateral optic papillitis following mycoplasma pneumoniae pneumonia. Opthalmologica 1998; 212:344-6.
  6. Lolly P, Rachita S, Satyasundar M. Ophthalmic manifestations of central nervous system tuberculosis-two case reports. Indian J Tuberc 2011; 58:196-8.
  7. Komolafe MA, Sunmonu TA, Esan OA. Tuberculous meningitis presenting with unusual clinical features in Nigerians: Two case reports. Cases J 2008; 1:180.
  8. Beal MF. Multiple cranial nerve palsies: A diagnostic challenge. N Engl J Med 1990; 322: 461-3.
  9. Garg RK, Somvanshi DS. Spinal tuberculosis: a review. J Spinal Cord Med 2011; 34:440-54.
  10. Rasouli MR, Mirkoohi M, Vaccaro AR, Yarandi KK, Rahimi-Movaghar V. Spinal tuberculosis: diagnosis and management. Asian Spine J 2012; 6:294-308.