1. Presumed tuberculosis-associated uveitis: rising incidence and widening diagnostic criteria in non-endemic area
Nikolas Krassas1, Jane Wells1, Christine Bell2, Mark Woodhead2,3, Nicholas Jones1,3
1. Manchester Royal Eye Hospital, Central Manchester University Hospitals NHS Foundation Trust: 2. Dept of Respiratory Medicine, CMFT:; 3. Medical Academic Health Science Centre, University of Manchester, UK
results
PURPOSE
Table 1. Complications during the 12-month observation period.
Complication
Number (%)
Vitreous haemorrhage (in occlusive Ret. Vasculitis) 3
4.1
Argon laser retinal ablation 11
14.9
Par plan Vitrectomy with pre-retinal membrane peel 1
1.4
Macular oedema 9
12.2
Secondary glaucoma 10
13.5
Drainage implants 5
6.8
Cataract operation
To assess the incidence, clinical ocular involvement and effectiveness of antituberculous treatment (ATT) in patients with presumed tuberculosis- associated uveitis (TBU) in a non-endemic community.
INTRODUCTION
Figure 1. Multifocal choroidal lesions in a patient with presumed TBU before (left) and 4 weeks after (right) commencing anti-tuberculous treatment.
The incidence of TB in England is low and has been reducing since 2011; overall incidence 12/100,000.
The areas of highest incidence (>40/100,000) are the cities of London, Manchester and Birmingham. Extra-pulmonary TB accounts for 47% of cases and has proportionately increased recently. TBU is not recorded separately by Public Health England.
TBU incidence and treatment outcomes up to 2007 have previously been reported from this centre2. Subsequently an increase in cases has been seen, and recently- described clinical manifestations are increasingly experienced3.
results
TBU was considered in 83 patients but 41 were excluded for reasons including incomplete follow-up or data, failure to complete full ATT and inactive TBU. In 3 cases, the diagnosis of sarcoidosis was made, following previous treatment for TBU. The remaining 42 patients (22 male, mean age 36.4, all UK-resident) were included.
Country of birth: 12 UK, 11 Pakistan, 9 India, 9 Africa, 2 Philippines.
Bilateral uveitis in 32 (76%; 6 anterior [AU], 4 intermediate, 22 panuveitis, 10 posterior. 12/32 with AU (37.5%) were granulomatous.
18 retinal vasculitis (occlusive in 12, retinal neovascularisation in 7), 7 multifocal choroiditis, 5 serpiginous-like chorioretinitis, 5 papillitis.
27 of 31 Mantoux tests had >15mm induration, the others 14, 12, 11 and 8mm (all 4 GIFN+). Gamma-interferon testing was performed in 39/42 patients and was positive in 37 (95%). Five patients had concurrent active pulmonary or nodal TB.
In addition to a 6-month course of ATT, topical steroids were used in 32 patients and oral prednisolone in 18 (43%); of these, 3 had used oral steroids for several months prior to the diagnosis of TBU; 5 commenced prednisolone 30-80mg/day at the same time as ATT; 9 commenced prednisolone 30-80mg/day 1-4 weeks after commencing ATT, and 1 commenced prednisolone 100mg/day 4 months after starting ATT, following inflammation recurrence. Six months after starting ATT, 10 patients were still using prednisolone, and 6 months later, 3 remained on oral steroid. Three patients required oral immunosuppression.
Complications observed during the 12-month observation period are shown in Table 1.
At 6 months after baseline, 27 patients (64.3%) had no intraocular inflammation and at 12 months, 29 patients (69%). At this stage 24 patients were off treatment, 15 were still using topical steroid, 3 required oral steroid and two, oral immunosuppression.
At 12 months after baseline, 35/74 eyes (47%) showed a significant improvement (0.2 LogMAR). 51/74 eyes (69%) had final VA of 0.1 LogMar or better.
objectives
Figure 2. Change in incidence of TB-associated uveitis at Manchester Uveitis Clinic
To document the changing incidence of TBU in Manchester
To describe the clinical signs at diagnosis
To document outcomes using the British Thoracic Society recommended 6-month anti-tuberculosis treatment (ATT) regime for TB.
conclusions
In this case series the most typical indicators of TBU were granulomatous panuveitis, atypical serpiginous-like chorioretinitis and occlusive retinal vasculitis
The incidence of TBU in Manchester has increased, requiring careful investigation in suspected cases²˒⁴
The results of standard UK 6-month ATT are disappointing and this shows no improvement on our previous cohort reported2, despite the introduction of GIFN testing to aid diagnosis. It may be that TB- associated uveitis requires more prolonged treatment
methods
Retrospective case series of patients with uveitis and evidence of tuberculosis (active TB at another site, or positive Mantoux test or γ-interferon test [GIFN] or both) with no other identified cause, identified between Jan 2008 and Dec 2014.
Qualifying uveitis: granulomatous keratic precipitates or iris nodules, steroid- resistant uveitis, intermediate uveitis, retinal vasculitis with or without occlusion, multifocal choroiditis, single choroidal tubercle, uveitis with papillitis, atypical placoid or serpiginous-like chorioretinitis.
Full 6-month course of standard ATT (2 months of rifampicin, isoniazid, pyrizinamide and ethambutol followed by 4 months of rifampicin and isoniazid)
Visual acuity (VA), presence and type of inflammation were assessed at the commencement of ATT (baseline), at completion of treatment (6 months), and 6 months later. Details of concurrent oral steroid treatment and/or immunosuppression were noted.
REFERENCES
1. Anon. Tuberculosis in England 2015 report. Public Health England 2015
2. Sanghvi C, Jones NP, Bell C, Woodhead M, Hardy C. Presumed tuberculous uveitis: diagnosis, management and outcome. Eye 2011;25:475-80
3. Gan W-L, Jones NP. Serpiginous-like choroiditis as a marker for tuberculosis in a non-endemic area. Br J Ophthalmol 2013;97:644-7
4.Bell C. Tuberculosis in Manchester and Trafford Annual Report Dept Resp Med, Central Manchester Foundation Trust 2015
Declaration of interest: The authors report no conflicts of interest.