Solitary Choroidal Tuberculoma
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reduction in size of the tuberculoma to 0.75 dd (Panel B) enlarge image |
A previously healthy, US-born, white, 37-year-old man was admitted to the hospital complaining of months of low-grade fevers and a 10 lb weight loss, 3 days of blurry vision in the right eye and 1 day of fever to 106 ° F and shortness of breath with scanty sputum production. His HIV status was unknown but he reported having a sexual partner who was HIV-infected. On examination, he had an afferent pupillary defect and decreased visual acuity of the right eye without meningeal signs. Results of a contrast-enhanced computed tomography (CT) scan and magnetic resonance imaging of the head and a lumbar puncture were normal. On retinal examination, a solitary, white, sub-retinal, elevated mass measuring 1.5 disk diameter (dd) was noted infero-temporally to the optic disc, with minimal surrounding sub-retinal fluid, consistent with a choroidal granuloma (Panel A) . A chest x-ray film and CT scan showed hilar adenopathy with necrosis and innumerable miliary nodules. His un-induced sputum contained acid-fast bacilli, culture of which grew Mycobacterium tuberculosis. Cultures and antigen tests for bacterial and fungal organisms were negative. He tested positive for HIV antibody and had a CD4 cell count of 174 cells/mm 3 .
Choroidal tuberculoma is an established complication of miliary tuberculosis, present in about 28 percent of cases . The afferent papillary defect observed in our patient also suggested a vasculitic process and therefore systemic steroid treatment was added to ethambutol , rifampin, isoniazid and pyazinamide. His fever and blurry vision resolved after one week of treatment and a follow-up retinal exam revealed a reduction in size of the tuberculoma to 0.75 dd (Panel B).
Bo Shopsin, M.D., Ph.D.
Sumathi Sivapalasingam, M.D.
Bellevue Hospital and the VA Medical Center
New York, NY, 10016
