A 29-year-old Burmese woman with human immunodeficiency virus (HIV) infection who had been diagnosed with pulmonary tuberculosis was initially treated with isoniazid 300 mg/day, rifampicin 450 mg/day, pyrazinamide (unknown dosage), and ethambutol 800 mg/day for 2 months. After a 2-month course of this four-drug regimen, pyrazinamide was discontinued. Five months after the initiation of ATT, the patient developed pain, redness, and blurred vision in her right eye. Two weeks later, her right eye became no light perception and exhibited proptosis with the presence of purulent discharge. Orbital computed tomography (CT) showed large intraconal, periorbital, and preseptal abscesses. She was then admitted to the primary care hospital and was treated for orbital cellulitis with a 1-g ceftriaxone infusion twice daily. Oral ciprofloxacin 500 mg twice daily was added 4 days later. Tobramycin eye drops 0.3% four times daily and tobramycin eye ointment twice daily were given.
The result of a conjunctival pus swab was positive for 1+ acid-fast bacilli (AFB), and a culture revealed clusters of Staphylococcus spp. Despite an escalation of ATT and antibiotics for 1 week, the patient’s clinical condition continued to worsen. She was then referred to our institution, Siriraj Hospital, Thailand’s largest university-based tertiary referral center. Upon arrival, her right eye showed marked chemosis with a large subconjunctival inferotemporal abscess (Fig. 1a). She had 3+ anterior chamber cells, mutton-fat keratic precipitates, ectropion uvea, and iris neovascularization. Exophthalmometry at 104-mm base showed a protrusion of the right eye of 20 mm, compared with 13 mm in the left eye. The right lateral gaze and down gaze of her right eye were limited at 5 and 10 degrees, respectively. A dilated fundus examination showed a dense vitreous hemorrhage. An unclear subretinal lesion was identified. Her left eye was unremarkable. B-scan ultrasonography of her right eye showed an irregular globe contour and inhomogeneous vitreous echogenicity. A 13.3 mm×15 mm mass with a high initial A-scan spike and low to moderate internal reflectivity was identified underneath a high A-scan spike membrane-like lesion that extended beyond the globe into the orbital cavity (Fig. 1b).
Orbital CT was repeated, which showed an intraocular multiloculated ring contrast-enhanced mass that extended to the right orbit (Fig. 1c and d). The optic nerve, lateral rectus muscle, and inferior rectus muscle of the right eye were enlarged. The conjunctival pus swab was repeated, which stained positive for AFB. The patient’s CD4 cell count was 123 cells/mm3. An infectious disease (ID) specialist immediately ordered second-line ATT (750-mg amikacin infusion, 500-mg levofloxacin infusion, oral clarithromycin 1 g/day, and para-aminosalicylic acid 8 g/day). With the fact that the infection was intense and was not responding to conventional ATT, despite the previous 5 months of ATT treatment. The risk of progression to the central nervous system was weighed against preservation of the eyeball. With a discussion between the patient and the medical team, a decision was made to perform subtotal orbital exenteration. A large number of scleral and intramuscular tuberculomas were identified. One large subretinal abscess (14 mm×10 mm×10 mm) was present that extended to the orbital cavity through a scleral perforation. Pathological study of exenterated tissue revealed chronic granulomatous inflammation and caseous necrosis, which was positive for AFB stain and compatible with mycobacterial infection (Fig. 2). Cultured tissue was negative for mycobacterium. Three months later, the result of a conjunctival pus swab culture was positive for drug-susceptible Mtb. The ID specialist recommended continuation of the second-line oral ATT for 18 more months. There was no sign of recurrent tuberculous mycobacterium infection around the exenterated wound at the patient’s last visit, the 6-month follow-up, at Siriraj Hospital. After that visit, she was transferred back to her primary care hospital to complete her course of treatment. Highly active antiretroviral therapy, or HAART, was initiated afterward at the primary care hospital according to the health care policy in Thailand.
