Posterior scleritis. 2 (4%). 6 (16%). 0.16. Intravitreal inflammatory cells. 5 (11%). 4 (11%). 1.00. Multifocal choroiditis. 9 (20%). 1 (3%). 0.04. Choroidal granuloma.
Acta Ophthalmologica 2014
Tuberculous uveitis in China Yu Mao,1 Xiao Yan Peng,1 Qi Sheng You,1 Hong Wang,2 Meng Zhao2 and Jost B. Jonas3 1 Beijing Institute of Ophthalmology, Beijing Ophthalmology and Visual Science Key Lab, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China 2 Department of Ophthalmology, Beijing Ophthalmology and Visual Science Key Lab,Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China 3 Department of Ophthalmology, Medical Faculty Mannheim of the Ruprecht-Karls-University of Heidelberg, Mannheim, Germany
ABSTRACT. Purpose: To assess tuberculous uveitis in Chinese patients. Methods: The hospital-based observational case series study included patients who attended a third-referral hospital and presented with chronic and recurrent uveitis without primarily detected aetiology. The patients underwent the tuberculin skin test (TST) and/or interferon gamma release test (IGRA). Patients with positive test results received standard antituberculous therapy. Patients who responded to the therapy and did not show recurrence of uveitis in the follow-up period were diagnosed as tuberculous uveitis and formed the study group. The remaining patients were diagnosed as non-tuberculous uveitis and formed the control group. The clinical characteristics were compared between both groups. Results: The study group with tuberculous uveitis included 46 patients and the non-tuberculous group 38 patients. Multifocal choroiditis [n = 9 (20%) versus n = 1(3%); p = 0.04] and retinal vasculitis [n = 25(54%) versus 8 = (21.1%); p = 0.002] were significantly more common in the study group. Of 25 patients with retinal vasculitis in the study group, 11 patients (44%) additionally showed choroiditis lesions, compared with only one (13%) of eight patients in the control group (p = 0.01). In multivariate regression analysis, multifocal choroiditis [odds ratio (OR): 32.1], choroidal granuloma (OR: 21.4) and retinal vasculitis (OR: 11.2) were independent predictors of tubercular uveitis. Conclusions: About 50% of a group of 84 patients with primarily unexplained chronic posterior uveitis had tuberculosis and showed multifocal choroiditis, choroidal granuloma and retinal vasculitis. These features had a high predictive value for the diagnosis of tuberculous uveitis. Tuberculosis is an important part in the differential diagnosis of unexplained uveitis. Key words: choroidal granuloma – retinal vasculitis – tuberculosis – tuberculous uveitis – uveitis
Acta Ophthalmol. 2014: 92: e393–e397 ª 2014 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
doi: 10.1111/aos.12351
Introduction The Global Burden of Disease Study 2010 has recently estimated that tuberculosis deadly affected about 1.2 million people in 2010 and ranked on 12th position in the global list of disability
adjusted life years (Lozano et al. 2012; Murray et al. 2012). Despite the endemic prevalence of tuberculosis in China, only few studies addressed ocular tuberculosis in China. Figures reported by Abrahams and Jiang (Abrahams & Jiang 1986) and Yang
and colleagues (Yang et al. 2002) on a prevalence of tuberculosis of 4% and 0.7%, respectively, among all patients with uveitis in China were unexpectedly low as studies from other countries revealed higher numbers, such as from Japan with 6.9%, from Saudi Arabia with 10.5% and from India with 5.6–10% (Islam & Tabbara 2002; Wakabayashi et al. 2003; Rathinam & Namperumalsamy 2007). Considering the endemic prevalence of tuberculosis in China, it was likely that the prevalence of tuberculous uveitis was underestimated, potentially due to the difficulty in making a definite diagnosis of ocular tuberculosis (VasconcelosSantos et al. 2009; Sanghvi et al. 2011). We therefore carried out a hospital-based study in a third-referral centre in Beijing on patients suffering from uveitis of thitherto unknown aetiology, to address the questions how often in these patients tuberculosis as causative disease for uveitis could be detected and under which clinical signs it presented. The knowledge of such data could be helpful for the discussion on the prevalence of tuberculous uveitis in the group of patients with uveitis, could be helpful for the detection of tuberculous uveitis in clinical routine and could help to revive the importance of tuberculosis in the management of patients with ‘idiopathic’ uveitis.
Patients The observational hospital-based case series study included patients who consecutively attended the hospital with symptoms of posterior uveitis, intermediate uveitis, panuveitis, and/
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Acta Ophthalmologica 2014
or retinal vasculitis in the period from March 2011 to March 2013. Inclusion criterion was a chronic or recurrent posterior uveitis, intermediate uveitis, panuveitis or retinal vasculitis, which was therapy resistant to the use of corticosteroids or immunosuppressive drugs, and for which no reason was detected. The diagnostic work-up consisted of taking a detailed history, a general medical examination with additional X-ray or computed tomography of the chest, tuberculin skin testing, interferon gamma release test (T-SPOT.TB, Oxford Immunotec Co, Oxford, UK) (Gupta et al. 2007; Llorenc et al. 2013), examinations of urine and stool, and blood tests including immunological tests for syphilis, hepatitis B and C, human immunodeficiency virus, the TORCH tests (toxoplasmosis, other etymology: including rubella, cytomegalovirus, and herpes), rheumatoid factor, erythrocyte sedimentation rate, concentrations of C-reactive protein, antinuclear antibody and antineutrophil cytoplasmic antibodies. All patients also underwent a detailed ocular examination. Patients with latent tuberculosis (induration ≥20 mm on the tuberculin skin test and/or a positive interferon gamma release test) and patients with systemic manifest tuberculosis started an antituberculous therapy consisting of isoniazid, rifampicin, pyrazinamide and ethambutol. Although the World Health Organization guidelines recommended an induration with a diameter of at least 15 mm as a positive tuberculin test, we used the cut-off value of 20 mm to avoid falsely positive results in our Chinese patients. Patients receiving the antituberculous therapy were initially re-examined every 2 weeks for a period of 8 weeks. After that, re-examinations were carried out in intervals of 2–3 months. If patients showed a positive response to the antituberculous therapy after 4–6 weeks (defined as resolution, or at least remission, of ocular inflammation), they continued receiving the standard antituberculous therapy according to the Centers for Disease Control guidelines for a minimum of 6 months. This consisted of 2 months of a four-drug therapy (isoniazid, rifampicin, pyrazinamide and ethambutol) followed by a period of 4 months with isoniazid and rifampicin (Punnoose et al. 2013). Systemic corticoster-
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oids were added in some patients, at a dose of 1 mg/kg/day initially, commencing not earlier than 2 weeks after the initiation of the antituberculous therapy. The steroid treatment was tapered off slowly. The study participants were divided into two groups. The study group consisted of patients who had a positive response to the antituberculous therapy and who were diagnosed to have a tuberculous uveitis. A positive response to the antituberculous therapy was defined as resolution of the intraocular inflammation with no recurrence after the end of the antituberculous therapy. The control group included patients who were diagnosed to have a non-tuberculous uveitis, as they had a negative tuberculin skin test (induration
