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Year : 2021  |  Volume : 1  |  Issue : 1  |  Page : 55-57

Conjunctival tuberculosis: A report of two cases

Department of Cornea, Cataract, Refractive Surgery, Visakha Eye Hospital, Visakhapatnam, Andhra Pradesh, India

Date of Submission07-Jun-2021
Date of Decision21-Jul-2021
Date of Acceptance31-Jul-2021
Date of Web Publication01-Nov-2021

Correspondence Address:
Dr. Ramya Seetam Raju
Visakha Eye Hospital, 8-1-64, Pedda Waltair, Visakhapatnam-17, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jocr.jocr_2_21

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India has the highest burden of tuberculosis (TB) in the world. In the last few years, there has been a re-emergence of the disease. Ocular TB is a form of extrapulmonary TB. Conjunctival TB is a relatively rare presentation of ocular TB. This report describes two such cases of TB of conjunctiva. One case presented with redness and pain in the right eye of 1-month duration. Examination revealed a conjunctival nodule. The other case presented with a mass in the left eye which showed a pink nodule. The presence of a conjunctival nodule with unresponsiveness to topical steroids and antibiotics was the common feature in both cases. Histopathology showed tuberculous inflammation and antituberculous therapy helped in the resolution of the lesions. Thus, in cases of conjunctival nodules unresponsive to steroids, TB should be suspected and a timely biopsy should be done, especially in a country like ours, which is endemic for TB.

Keywords: Antituberculous therapy, conjunctival nodules, conjunctival tuberculosis, tuberculosis

How to cite this article:
Raju RS, Raju C V, Rupali C. Conjunctival tuberculosis: A report of two cases. J Ophthalmol Clin Res 2021;1:55-7

How to cite this URL:
Raju RS, Raju C V, Rupali C. Conjunctival tuberculosis: A report of two cases. J Ophthalmol Clin Res [serial online] 2021 [cited 2023 Sep 23];1:55-7. Available from: http://www.jocr.in/text.asp?2021/1/1/55/329773

  Introduction Top

There has been tremendous development in the management of tuberculosis (TB) disease over the last few decades. Yet, Mycobacteriae continue to intrigue the physician with their persistence and myriad clinical presentations. India has an estimated incidence of 26.9 lakh cases in 2019 (WHO).[1] Ocular TB is a type of extrapulmonary TB. The most common presentation is tuberculous uveitis.[2] While conjunctival involvement is more common with systemic disease, isolated conjunctivitis has been reported.[3] Two cases of conjunctival TB are described. These reports add to existing ones, increasing the awareness about the disease and highlighting the need for a high index of suspicion.

  Case Reports Top

Case 1

A 12-year-old boy presented with redness and pain in the right eye of 1-month duration. He was on topical antibiotics and steroids but without improvement. There was no history of systemic abnormality or infective or immunological disease in the family. A single, spherical pinkish white nodule of size 4 mm × 4 mm was seen on the superior bulbar conjunctiva, adjacent to the limbus at 11–12 O' clock position in the right eye [Figure 1]. It was surrounded by dilated episcleral vessels. Fundus was normal. Visual acuity was 6/6. Other eye was within normal limits. It was diagnosed as phlyctenular conjunctivitis and treated with topical steroids but was unresponsive. A pediatric consultation did not pick up any systemic abnormality. Complete blood picture (CBP), erythrocyte sedimentation rate (ESR) at 1 hour and peripheral blood smear were all within normal limits. Mantoux test was negative and X-ray chest was normal. Excision biopsy and histopathology showed multiple epitheloid cell granulomas with Langhans giant cells suggesting tuberculous inflammation. As there was no evidence of systemic infection, a diagnosis of primary conjunctival TB was made. The patient was started on antituberculous therapy (ATT) based on the advice given by the pediatrician. After 3 months of treatment, there was a complete resolution [Figure 2]. The patient was followed up for 2 years without any evidence of recurrence.
Figure 1: Pinkish white nodule on superior bulbar conjunctiva in Case 1

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Figure 2: Resolution of nodule following antituberculous therapy in Case 1

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Case 2

A 29-year-old woman presented with a painless reddish mass in her left eye of 1-month duration. She was on topical steroids and antibiotics without any alleviation of her symptoms. There was no history of systemic disease or significant family history. On examination, there was a single spherical pink nodule of size 3 mm × 3 mm in the inferotemporal quadrant of the bulbar conjunctiva [Figure 3]. Fundus was normal and visual acuity was 6/6. Other eye was normal. CBP, ESR, and peripheral blood smear were normal. X-ray chest did not reveal any pulmonary or mediastinal focus and Mantoux test was negative. Following an excision biopsy [Figure 4], histopathology showed epitheloid cell granulomas with multinucleate giant cells suggesting tuberculous inflammation as shown in [Figure 5]. Chest physician consultation revealed left-sided cervical lymphadenopathy. Fine needle aspiration cytology showed caseating, epitheloid cell granulomas indicating tuberculous etiology. Thus, conjunctival TB secondary to tuberculous cervical lymphadenitis was diagnosed. ATT was started based on the advice of the chest physician. The remnant nodule and lymphadenopathy resolved. There was no recurrence at 6 months.
Figure 3: Pink conjunctival nodule in inferotemporal bulbar conjunctiva of Case 2

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Figure 4: Appearance following biopsy in Case 2

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Figure 5: Hematoxylin and eosin staining of the conjunctival specimen at ×400 magnification showing granulomas with epithelioid cells (arrows) with multinucleate giant cells (circles)

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  Discussion Top

TB is still a major cause of ill health and the leading cause of death from a single infectious agent (ranking above human immunodeficiency virus acquired immunodeficiency syndrome).[4] India is one of the 8 countries which account for two-thirds of its global burden.[4] Ocular TB usually occurs because of spread from pulmonary or extrapulmonary TB. The route can be (a) hematogenous – the most common, (b) primary exogenous infection, (c) secondary infection from contiguous area or patient's sputum, and (d) as a result of hypersensitivity as in phlyctenular conjunctivitis or Eale's disease.[5],[6] Primary conjunctival TB is an infrequent presentation. Here, bacilli enters through the conjunctiva.[7] Mode of infection is by exogenous infection, direct inoculation from infected individuals, articles, contaminated fingers, or milk.[7] Secondary tuberculous conjunctivitis occurs as a result of spread of infection from a contiguous focus or from the patient's sputum. Such an infection can occur on the lids, cornea, sclera, or the lacrimal sac.[5],[6] TB may also masquerade as conjunctivitis.[3],[8] Diagnosis requires identification of the organism with acid-fast bacillus stains or culture but is difficult in ocular TB due to the low yield and small size.[2] Polymerase chain reaction (PCR) can detect Mycobacterium tuberculosis on either a conjunctival smear or a biopsy sample in cases where the bacillary load is less.[8] Chaurasia et al. described criteria for definitive diagnosis of tuberculous conjunctivitis in patients with recurrent conjunctivitis – (i) microbiological criteria: positive smear or culture or positive PCR for M. tuberculosis; (ii) histopathological criteria: caseating granulomas or epithelioid giant cells in conjunctival biopsy samples with or without isolation of acid-fast bacilli; (iii) clinical criteria: presence of systemic signs of TB and/or positive response to anti-TB therapy.[8] The first case was primary conjunctival TB. The second case, we presume, could have been due to hematogenous spread from underlying extrapulmonary TB, i.e., cervical lymphadenitis, as it is the most common route. Both cases responded to ATT. This consisted of 2 months of isoniazid, rifampicin, ethambutol, and pyrazinamide and 4 months of rifampicin and isoniazid. The dose was adjusted according to the weight in the first case. Thus, TB could be the etiology underlying symptoms such as redness, pain, or nodules. A high index of suspicion and an early diagnostic procedure may minimize the ocular morbidity. Furthermore, underlying systemic disease may be revealed.

The limitation of this report is that acid-fast bacilli were not demonstrated. This was because the index of suspicion for conjunctival TB was not high. However, histopathology had proven tuberculous inflammation. The remarkable resolution of lesion with ATT and the lack of recurrence proved the etiology without doubt.

  Conclusion Top

In an area endemic for TB like India, for any limbal nodule, TB should be considered apart from the usual phlycten, especially if unresponsive to steroids. The clinician ought to have a high index of suspicion and should not hesitate to go about with biopsy, histopathology, and systemic workup for TB.

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

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Conflicts of interest

There are no conflicts of interest.

  References Top

Kanabus, Annabel. Information about Tuberculosis, GHE: 2020. Available from: https://tbfacts.org/tb-statistics/. [Last accessed on 2021 May 25].  Back to cited text no. 1
Gupta A, Sharma A, Bansal R, Sharma K. Classification of intraocular tuberculosis. Ocul Immunol Inflamm 2015;23:7-13.  Back to cited text no. 2
Rose JS, Arthur A, Raju R, Thomas M. Primary conjunctival tuberculosis in a 14 year old girl. Indian J Tuberc 2011;58:32-4.  Back to cited text no. 3
Global Tuberculosis Report 2019. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO. Available from: https://apps.who.int/iris/handle/10665/329368. [Last accessed on 2019 Oct 15].  Back to cited text no. 4
Dalvin LA, Smith WM. Orbital and external ocular manifestation of Mycobacterium tuberculosis: A review of the literature. J Clin Tuberc Other Mycobac Dis 2016;4:50-7.  Back to cited text no. 5
Gibson WS. The etiology of phlyctenular conjunctivitis. Am J Dis Children 1918;15:81-115.  Back to cited text no. 6
Deschenes J, Wade NK, Lalonde R. Tuberculosis and atypical Mycobacteria. In: TasmanW, Jaeger E, editors. Duane's Ophthalmology. Philadelphia, PA: Lippincott, Williams and Wilkins; 2006.  Back to cited text no. 7
Chaurasia S, Ramappa M, Murthy SI, Vemuganti GK, Fernandes M, Sharma S, et al. Chronic conjunctivitis due to Mycobacterium tuberculosis. Int Ophthalmol 2014;34:655-60.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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