Bilateral choroidal tuberculoma in a patient of miliary tuberculosis

TL;DR

A young woman with miliary tuberculosis developed bilateral choroidal granulomas, which were treated with a combination of anti-VEGF, moxifloxacin, steroids, and anti-tubercular therapy.

Contribution

This case highlights the use of intravitreal anti-VEGF and moxifloxacin as adjunctive treatments for managing large choroidal tuberculomas.

Findings

Weekly intravitreal injections of anti-VEGF and moxifloxacin helped consolidate and scar TB granulomas.

Combination therapy with ATT and steroids controlled inflammation effectively.

Optical coherence tomography showed reduced choroidal bump size after treatment.

Abstract

Choroidal granuloma is one of the common manifestations of ocular tuberculosis. Tubercles indicate hematogenous dissemination of the disease. Tubercular granulomas respond to Anti-Tubercular Treatment (ATT) and systemic corticosteroids. However, in some patients with large granulomas involving macula, adjunct treatment with intravitreal anti-VEGF may be required for prompt management of the granuloma.

We report a case of bilateral Tubercular granuloma in a patient with miliary Tuberculosis (TB). The patient was an immunocompetent young female with miliary tuberculosis. Mantoux was positive. HRCT chest suggested miliary TB. The patient was already on ATT. Clinical examination showed multiple TB granulomas in both eyes, with a large granuloma involving the fovea in the left eye. She underwent intravitreal injection of the anti-VEGF drug bevacizumab (1.25 mg/0.05 mL) (off-label use) with moxifloxacin (500 µg/0.1 mL) (off-label use) in the left eye. She was continued on ATT and was started on oral steroids. After seven weekly intravitreal injections in the left eye at the second-month follow-up, lesions were consolidated and scarred. Optical coherence tomography showed a decrease in the size of the choroidal bump.

Weekly administration of intravitreal Anti-Vascular endothelial growth factor(VEGF) and moxifloxacin, along with ATT and oral corticosteroids, has controlled inflammation and has caused consolidation and scarring of TB granulomas in a patient with miliary TB.

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