Manfred Zierhut Centre of Ophthalmology University of Tuebingen, Germany Retinal Vasculitis First Presentation Ocular History June 2006 43 year old African man OS: painful eye First Presentation General History healthy First Presentation Ocular Examination OU VA: 1.0/0.63 IOP: 18/48 mmHg AC: 2+ cells, post. synechiae First Presentation Ocular Examination Fundus OU: massive vessel occlusion neovasc. of the optic disc small granuloma like changes First Presentation Fundus OD First Presentation FLA OD First Diagnosis Panuveitis with occlusive vasculitis of unclear origin First Presentation Investigastions chest X-ray and CT: negativ ACE 34 (8-21) HIV, syphilis: negativ thalassemia + (heterocygote) no sickle cells detectable First Presentation First Treatment Corticosteroids syst. Lasercoagulation Mycophenolate mofetil Avastin Improvement of uveitis Follow up First Treatment antiglaucomatous topical drugs corticosteroids syst. lasercoagulation Follow up After 1 -3 Months improvement of inflammation, less the neovascularisation corticosteroids syst. continued lasercoagulation mycophenolate mofetil avastin Follow up After 1 to 9 Months July 2006 to March 2007 neovascularization of OD red. more ischemia peripheral more AC cells, IOP increased systemic corticosteroids, lasercoagulation avastin Follow Up After 9 Months inflammation reduced, but neovascularisation still detectable Follow Up After 12 Months June 2007 planned TNF-alpha blocking agents Quantiferon-test: positive Second Diagnosis panuveitis with occlusive vasculitis probably of TB origin but no other signs of TB detectable Follow Up After 13 Months July 2007 PET-CT scan PET/CT-Scanner 2. PET PET 1. Spiral CT CT 3. Fusion Combination of PET and CT PET-Tracer: FDG (Fluor-18-Desoxyglucosis) Trapping inflammation tumor PET/CT - Scan enrichment of tracer in paratracheal lymph nodes followed by biopsy KM-CT Fusion PET+CT SUV 2.4 Results of Biopsy PCR for TB: negative PCR for TB: negative biopsy: non caseating granulomas biopsy: non caseating granulomas diagnosis: Sarcoid diagnosis: Sarcoid planned therapy: TNF-alpha blocking agents planned therapy: TNF-alpha blocking agents Phone call after 3 weeks positive TB - culture positive TB - culture Follow Up After 16 Months October 2007 start anti-TB treatment start anti-TB treatment Follow Up Next Months October 2007 clinically stable findings clinically stable findings regression of neovascularisations regression of neovascularisations occasionally intravitreal bleedings occasionally intravitreal bleedings occasionally mild IOP increase occasionally mild IOP increase Follow Up After 22 Months April 2008 back from Africa back from Africa massive increase of liver enzymes massive increase of liver enzymes stop of anti-TB treatment due to toxicity stop of anti-TB treatment due to toxicity Last Control After 94 Months October 2014 VA: 1.0/0.9 VA: 1.0/0.9 IOP: 18/22 mmHg IOP: 18/22 mmHg no AC cells, no neovascularisation no AC cells, no neovascularisation treatment: topical anti-IOP drugs treatment: topical anti-IOP drugs Change of Paradigm TB: Infectious disease creates the problems but may initiate an immune response which may lead to uveitis diagnosis: Chest-X-Ray, Mantoux but in case of strong suggestion of TB QuantiFERON and PET-CT-Scan with biopsy and culture problem: immune-mediated (latent?) TB probably everywhere Implications for Diagnosis Tuberculosis: PCR less effective as culture specificity of quantiferon test may be higher than suggested in the literature Sarcoidosis: positive biopsy no proove of sarcoid !! induced by TB? Implications for TB-Treatment infectious TB anti TB-treatment non-infectious (latent, immune-mediated) TB anti-TB T-cells exist (+ Quantiferon Test) despite massive IS: no generalisation anti-TB with immunosuppressives Ag-Presentation TB Antigen Uveitis T-Cells B-Cells Infectious TB Immune-mediated TB Conclusion TB may mimic sarcoid until the level of biopsy infectious and immenumediated TB can induce panuveitis with retinal vasculitis treatment consists of anti-TB-treatment and probably even immunosuppressive treatment