Imitation game: Ocular tuberculosis camouflaged as acute retinal necrosis

Aims/Purpose: To report a case of ocular tuberculosis (TB) mimicking acute retinal necrosis (ARN) Methods: Case report Results: A 32‐year‐old immigrant, presented with right eye blurring of vision for 2 months and associated with 1 week history of floaters. The left eye was blind since 8 years ago with a history of progressive blurring of vision. He did not seek any medical attention at that time due to financial constraint. Otherwise, he denies any constitutional or autoimmune disease symptoms. On examination, visual acuity of the right eye was 6/36 and left eye was non‐perception to light in all 4 quadrants. There was positive relative afferent pupillary defect on the left eye. Anterior segment examination of the right eye was normal and fundus examination showed presence of vitritis 3+ with multiple foci of retinitis 360 degrees peripherally, oedematous retina with confluent retinitis at superonasal and areas of haemorrhage nasally. Left eye showed white cataract and B‐scan revealed total retinal detachment (RD) posteriorly. He was treated for right eye ARN in view of typical peripheral retinal involvement with haemorrhages and left eye RD. He was started on intravenous Acyclovir 100mg/kg/dose TDS and was given 2 times of intravitreal Ganciclovir. Unfortunately, the symptoms worsened with deteriorating visual acuity throughout admission, and he was referred to medical retina team and the diagnosis revisited. Mantoux test showed positive result with 24mm with blister. However vitreous TB and viral polymerase chain reaction (PCR) were negative. Fundus fluorescein angiogram showed presence of hot disc and multiple peripheral vessel leakages from all quadrants. The diagnosis was revised to right eye ocular TB. Patient was co‐managed with medical team and anti‐TB medications were commenced. His symptoms improved tremendously with visual acuity of 6/9. Conclusions: Ocular TB is a great masquerader. High index of suspicion and thorough investigations are required to diagnose an atypical uveitis presentation especially in TB endemic areas such as in this case. Multidisciplinary approach is vital in treating tuberculosis to monitor for multisystem involvement.