Tubercular chorioretinitis mimicking sarcoidosis in a patient with celiac disease and erythema nodosum: A case report

Abstract

BACKGROUND

Tuberculosis remains an important cause of uveitis in tuberculosis-endemic regions and can closely resemble other granulomatous disorders, such as sarcoidosis, especially in the presence of erythema nodosum. The diagnosis is even more challenging in the presence of an underlying autoimmune condition such as celiac disease.

CASE SUMMARY

We report a case of a middle-aged female, a known case of celiac disease and recurrent severe anaemia presenting with progressive, recurring episodes of bilateral diminished vision, ocular pain, photophobia, and floaters over a period of 1.5 years. Ocular examination revealed bilateral vitritis with chorioretinal lesions consistent with posterior uveitis, more severe in the left eye. Initially, the presence of erythema nodosum and systemic symptoms raised the possibility of sarcoidosis; however, an extensive systemic workup ruled it out. A positive QuantiFERON-TB Gold test, past history of treated cervical lymph node tuberculosis, relevant family history, and favourable clinical response to antitubercular therapy favoured the diagnosis of presumed tubercular chorioretinitis. The treatment included antitubercular therapy, systemic corticosteroids, and posterior subtenon triamcinolone injections which led to clinical improvement; however, there was a recurrence of the disease after completing treatment, which required initiation of systemic azathioprine.

CONCLUSION

This case highlights the need for a high index of suspicion for ocular tuberculosis in patients presenting with posterior uveitis and erythema nodosum. Detailed assessment and exclusion of close differentials are essential so that timely diagnosis and optimum management can be done, especially in endemic areas.

Keywords: Tubercular uveitis; Erythema nodosum; Sarcoidosis; Celiac disease; Panuveitis; Case report

Core Tip: This case underscores the diagnostic challenges posed by posterior uveitis in patients with underlying autoimmune conditions such as celiac disease and recurrent anemia, especially in tuberculosis-endemic regions. The presence of erythema nodosum and systemic symptoms can mimic other granulomatous diseases like sarcoidosis, making timely and accurate diagnosis difficult. However, a comprehensive evaluation including immunological testing, history of tuberculosis, family history, and response to antitubercular therapy was pivotal in establishing presumed tubercular chorioretinitis as the diagnosis. The case highlights the importance of maintaining a high index of suspicion for ocular tuberculosis and the need for a multidisciplinary approach to management, utilizing antitubercular drugs, corticosteroids, and immunosuppressants when necessary, to achieve optimal clinical outcomes.