A 12-year-old girl (Figure 1) presented with complaints of pain, redness, and watering in her right eye for 5 days. She was thinly built and appeared well on the general physical examination. On ophthalmic examination, her corrected visual acuity was 6/6 in both eyes. In the right eye only, diffuse scleral and episcleral congestion with scleral thinning was noticed temporally, along with 1+ cells in the anterior chamber. The pupil was semi-dilated and sluggishly reacting to light. Intraocular pressure on applanation tonometry was 14 and 12 mm Hg in her right and left eyes, respectively. Funduscopy of her right eye revealed a mild vitreous haze with unremarkable optic discs. The ophthalmic examination of her left eye was within normal limits. Treatment was started in the form of topical steroids, antibiotics, and cycloplegics. She presented 2 weeks later with a visual acuity of 6/12 on ocular examination with 4+ cells in the anterior chamber and active patches of choroiditis in the right eye. Her blood test results revealed leukocytosis and an elevated erythrocyte sedimentation rate. A chest x-ray showed opacities in the left lung, which raised a suspicion of pulmonary tuberculosis. The Mantoux test (tuberculin skin test) resulted in a 25-mm induration. Further evaluation included high-resolution computed tomography of her chest, which revealed a fibronodular calcified lesion in the left lower lung, with a few mediastinal nodes suggestive of chronic Koch's infection, thereby ruling out childhood sarcoidosis. Magnetic resonance imaging of her brain and orbits was performed to rule out any masquerade syndromes, and it yielded a negative result. The symptoms improved remarkably with systemic antitubercular treatment and oral steroids. The standardized World Health Organization antitubercular therapy regimen included 2 months of intensive phase (isoniazid, rifampicin, pyrazinamide, and ethambutol) followed by 4 months of continuation phase (isoniazid, rifampicin, and ethambutol) in fixed dosage combinations.
What's Your Diagnosis?
For the correct answer, see page 193.
The answer for What's Your Diagnosis? is tubercular sclerouveitis.
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