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眼結核中的匍匐樣脈絡膜炎

眼結核中的匍匐樣脈絡膜炎

資料來源:穆迪特·泰吉 (Mudit Tyagi)、庫什布·喬漢 (Khushboo Chauhan) / www.thelancet.com/infection / Vol 23 July 2023

 

     一名 40 歲印度女性因左眼視力下降 2 個月、右眼視力下降 1 週來院就診。 該患者沒有任何全身性疾病史。 沒有與結核病患者接觸史。 她右眼的最佳矯正視力為 20/160,左眼能夠數靠近臉部的手指。 視網膜評估顯示雙眼存在多灶性、兩側不對稱、廣泛的脈絡膜炎病變,呈鋸齒狀。 右眼病變活躍並累及黃斑,而左眼則散佈著活動性病變和已癒合的病變。

     實驗室檢查顯示 IFNγ 釋放試驗呈陽性,結核菌素皮膚試驗顯示有 18 毫米的硬結。 她的梅毒和愛滋病毒血清學檢測結果均為陰性。 她的胸部增強 CT 顯示沒有肺結核的證據,也沒有提示結節病的縱隔淋巴結腫大。 患者被診斷為匍匐樣脈絡膜炎,接受了9個月的抗結核治療,包括利福平rifampicin10 mg/kg)、異煙肼 isoniazid5 mg/kg)、吡嗪酰胺pyrazinamide25 mg/kg)和乙胺丁醇ethambutol15 mg/kg),同時靜脈注射三劑甲基潑尼松龍methylprednisolone1/天),隨後3個月逐漸減少劑量口服潑尼松龍prednisolone1毫克/千克)。 隨後,患者每月進行追蹤,抗結核治療反應良好,病灶消退。

     匍匐樣脈絡膜炎是結核性葡萄膜炎的特徵性表型表現。 匐匐樣脈絡膜炎的病變是多灶性的,不累及視乳頭旁區域,並累及後極、中周和視網膜周邊。 然而,在極少數情況下,結節病、梅毒和皰疹病毒也可導致匐行性脈絡膜炎。 IFNγ丙型干擾素釋放試驗和結核菌素皮試呈陽性有助於確定眼結核的診斷。 匍匐樣脈絡膜炎患者對抗結核治療反應良好。 為了在臨床實踐中進行有針對性的檢查並提供適當的治療,特別是在結核病流行的地方,需要對多灶性匐行性脈絡膜炎的臨床譜有深入的了解。

圖:匐行狀脈絡膜炎 (A) 右眼眼底照片,顯示多灶性廣泛活動性脈絡膜炎病變,呈累及黃斑的匐行模式。 (B) 左眼眼底照片顯示多灶性廣泛散佈的活動性和癒合性脈絡膜炎病變,呈鋸齒狀。

 

貢獻者

MTKC參與了患者的臨床評估和管理,患者提供了書面知情同意書。 MT KC 提出了手稿,並對手稿的起草、寫作和編輯做出了同等貢獻。

利益申報

我們聲明不存在競爭利益。

致謝

我們感謝 Rakshi Ugandhar Reddy 拍攝眼底照片。

 

Serpiginous-like choroiditis in ocular tuberculosis

Mudit Tyagi, Khushboo Chauhan

 

    A 40-year-old Indian woman presented to our hospital with complaints of diminution of vision in the left eye for 2 months and in the right eye for the past 1 week. The patient did not have a history of any systemic illness. There was no history of contact with anyone with tuberculosis. The best-corrected visual acuity was 20/160 in her right eye, and ability to count fingers close to her face in her left eye. A retinal evaluation revealed the presence of multifocal, bilaterally asymmetrical, widespread choroiditis lesions in a serpiginous pattern in both eyes. In the right eye, the lesions were active and involved the macula, whereas the left eye had both interspersed active and healed lesions.

    Laboratory investigations were positive for IFNγ release assay and the tuberculin skin test showed an induration of 18 mm. Her serology for syphilis and HIV was negative. Contrast-enhanced CT of her chest showed no evidence of pulmonary tuberculosis and no mediastinal lymphadenopathy suggestive of sarcoidosis. The patient was diagnosed with serpiginous-like choroiditis and received 9 months of anti-tubercular treatment, including rifampicin (10 mg/kg), isoniazid (5 mg/kg), pyrazinamide (25 mg/kg), and ethambutol (15 mg/kg), along with three initial doses of intravenous methylprednisolone (1 g/day) followed by 3 months of oral prednisolone (1 mg/kg) in tapering doses. Subsequently, the patient was followed-up on a monthly basis, and responded well to anti-tubercular therapy with regression of lesions.

    Serpiginous-like choroiditis is a characteristic phenotypic manifestation of tubercular uveitis. The lesions of serpiginous-like choroiditis are multifocal, sparing the juxtapapillary area, and involve the posterior pole, midperiphery, and retinal periphery. However, in rare cases, sarcoidosis, syphilis, and herpes virus can also lead to serpiginous-like choroiditis. A positive IFNγ release assay and tuberculin skin test helped in establishing the diagnosis of ocular tuberculosis. Patients with serpiginous-like choroiditis respond well to anti-tubercular therapy. To conduct specific targeted examinations and provide appropriate therapy in clinical practice, particularly in places endemic for tuberculosis, a significant understanding of the clinical spectrum of multifocal serpiginous-like choroiditis is required.

 

 

     一名 40 歲印度女性因左眼視力下降 2 個月、右眼視力下降 1 週來院就診。 該患者沒有任何全身性疾病史。 沒有與結核病患者接觸史。 她右眼的最佳矯正視力為 20/160,左眼能夠數靠近臉部的手指。 視網膜評估顯示雙眼存在多灶性、兩側不對稱、廣泛的脈絡膜炎病變,呈鋸齒狀。 右眼病變活躍並累及黃斑,而左眼則散佈著活動性病變和已癒合的病變。

     實驗室檢查顯示 IFNγ 釋放試驗呈陽性,結核菌素皮膚試驗顯示有 18 毫米的硬結。 她的梅毒和愛滋病毒血清學檢測結果均為陰性。 她的胸部增強 CT 顯示沒有肺結核的證據,也沒有提示結節病的縱隔淋巴結腫大。 患者被診斷為匍匐樣脈絡膜炎,接受了9個月的抗結核治療,包括利福平rifampicin10 mg/kg)、異煙肼 isoniazid5 mg/kg)、吡嗪酰胺pyrazinamide25 mg/kg)和乙胺丁醇ethambutol15 mg/kg),同時靜脈注射三劑甲基潑尼松龍methylprednisolone1/天),隨後3個月逐漸減少劑量口服潑尼松龍prednisolone1毫克/千克)。 隨後,患者每月進行追蹤,抗結核治療反應良好,病灶消退。

     匍匐樣脈絡膜炎是結核性葡萄膜炎的特徵性表型表現。 匐匐樣脈絡膜炎的病變是多灶性的,不累及視乳頭旁區域,並累及後極、中周和視網膜周邊。 然而,在極少數情況下,結節病、梅毒和皰疹病毒也可導致匐行性脈絡膜炎。 IFNγ丙型干擾素釋放試驗和結核菌素皮試呈陽性有助於確定眼結核的診斷。 匍匐樣脈絡膜炎患者對抗結核治療反應良好。 為了在臨床實踐中進行有針對性的檢查並提供適當的治療,特別是在結核病流行的地方,需要對多灶性匐行性脈絡膜炎的臨床譜有深入的了解。

Figure: Serpiginous-like choroiditis (A) Fundus photograph of the right eye showing multifocal widespread active choroiditis lesions in a serpiginous pattern involving the macula. (B) Fundus photograph of the left eye showing multifocal widespread interspersed active and healed choroiditis lesions in the serpiginous pattern.

Contributors

MT and KC were involved in the clinical evaluation and management of the patient, and the patient provided written informed consent. MT and KC proposed the manuscript and contributed equally to the drafting, writing, and editing of the manuscript.

Declaration of interests

We declare no competing interests.

Acknowledgments

We thank Rakshi Ugandhar Reddy for taking the fundus photograph.

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