Bilateral bumpy choroidal lesions in a young male

A 34-year-old gentleman misdiagnosed with ocular tuberculosis was later found to have choroidal metastases from lung adenocarcinoma. This case highlights the importance of multimodal imaging and systemic evaluation in differentiating intraocular malignancies from inflammatory conditions, especially in tuberculosis endemic areas, to ensure timely diagnosis and treatment of the metastatic disease. Case A 34-year-old Asian Indian gentleman presented with progressive vision loss in both eyes for the past 2 months. He was diagnosed elsewhere with bilateral tubercular (TB) choroidal granulomas, started on antitubercular therapy (ATT) and steroids, without any clinical improvement. Laboratory test reports already available with the patient revealed a Mantoux of 10 × 12 mm and left lung consolidation with pleural effusion on computed tomography (CT) chest. At presentation, his visual acuity was 6/12 in the right eye (OD) and 6/60 in the left eye (OS). Fundus examination OU revealed elevated creamy colored choroidal lesions at the posterior pole, choroidal striae, and overlying pigmentary changes [Fig. 1a and b]. In addition, left fundus showed an edematous optic disc. Fundus autofluorescence (FAF) revealed mixed hypo and hyper autofluorescence. Optical coherence tomography (OCT) through the lesions showed choroidal thickening with a lumpy bumpy contour and subretinal fluid [Fig. 1c and d].Figure 1: (a and b) Composite fundus photographs of both eyes reveal large, elevated, creamy-colored lesions at the posterior pole, associated with choroidal folds and areas of altered retinal pigmentation. (c and d) Fundus autofluorescence shows mottled areas of hyper- and hypoautofluorescence. OCT scans through the lesions show diffuse choroidal thickening with a characteristic lumpy-bumpy choroidal contour, presence of subretinal fluid, and scattered hyperreflective fociWhat will you do next? Continue treatment with ATT and oral steroids. Start empirical immunosuppressive therapy. Advise whole body 18-fluorodeoxyglucose positron emission tomography (FDG-PET) to identify primary focus of inflammation/infection and metastasis. Plan a diagnostic vitrectomy and do a choroidal biopsy. Findings and Management PET-CT scan revealed locally advanced FDG avid primary tumor in the left lung upper lobe with multiple metastases to left supraclavicular, mediastinal, and bilateral hilar lymph nodes, right lung, and skeletal system [Fig. 2]. On retrospective questioning, the patient reported intermittent fever, chest pain, dyspnea, and productive cough over the past 3 months, with severe backache and loss of appetite and weight for the past 1 month. He was immediately referred to a pulmonologist. Lung biopsy confirmed stage 4 lung adenocarcinoma. ATT and steroids were stopped, and systemic chemotherapy was initiated.Figure 2: Whole-body FDG PET-CT revealed a primary hypermetabolic lesion in the left lung upper lobe, with FDG avid left supraclavicular and paraaortic lymph nodes, bilateral hilar nodal involvement, right lung metastases, left pleural metastases, and multiple FDG avid sclerotic skeletal metastases involving the sternum, lumbosacral spine, bilateral pelvic bones, and proximal femursDiagnosis Advanced Lung Cancer with Choroidal metastasis. Correct answer C. Advise whole body 18-fluorodeoxyglucose positron emission tomography (FDG-PET) to identify primary focus of inflammation/infection and metastasis. Discussion Intraocular malignancies like choroidal metastases can closely mimic inflammatory conditions such as tubercular granulomas, posing significant diagnostic challenges. Distinguishing between them is critical, particularly in TB-endemic regions. Equivocal or positive Mantoux test and similar radiological chest findings may mislead the diagnosis. Choroidal metastases and tubercular granulomas can present with similar fundus appearances but have distinct OCT and autofluorescence features. On OCT, metastases show a lumpy-bumpy choroidal surface, internal hyperreflective foci, and overlying RPE disruption with subretinal fluid. In contrast, tubercular granulomas appear as smooth, dome-shaped, hypo-reflective choroidal masses with perilesional fluid.[1,2] FAF in metastasis typically shows mottled areas of hyper and hypo AF often described as a “leopard-spot pattern” due to RPE irregularity and damage.[3] A high index of suspicion for metastasis should be kept when imaging reveals bumpy choroidal features, prompting timely systemic evaluation. Multimodal ocular imaging and FDG PET-CT is crucial for early identification and appropriate management of metastatic disease. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.