Tuberculosis-related serpiginous choroiditis: aggressive therapy with dual concomitant combination of multiple anti-tubercular and multiple immunosuppressive agents is needed to halt the progression of the disease

Abstract

Background/purpose Serpiginous-like choroiditis is a rare immune-mediated sub-entity of tubercular uveitis with a usually deleterious outcome. Treatment is still controversial. The purpose in this case series is to indicate that only aggressive treatment comprising multiple anti-tubercular and multiple immunosuppressive agents seems to be able to halt the disease progression. Methods This retrospective case series included patients diagnosed with Interferon Gamma Release Assays (IGRA) -positive serpiginous choroiditis, seen at the Centre for Ophthalmic Specialized Care, Lausanne, Switzerland, treated with combined multiple antitubercular and immunosuppressive agents at presentation and having a sufficient follow-up. Disease history before referral, appraisal of disease, treatment modalities and follow-up were analyzed. Inclusion criteria were positive IGRA patients with serpiginous choroiditis with complete Spectral-Domain Optic coherence tomography (SD-OCT) and angiography images. Results From 2001 to 2020, 24 of 1525 new patients (0.26%) were diagnosed as serpiginous choroiditis. 10/24 were related to tuberculosis (positive IGRA and/or hyper-positive Mantoux test), 8/24 were IGRA negative and in 6 there was no information available. 4/10 tuberculosis related serpiginous patients fulfilled the inclusion criteria. Mean age was 39 ± 5.3 years. Snellen best corrected vision acuity (BCVA) at presentation in 3/4 where the macula was preserved was 0.96 ± 0.08. In 3/4 patients, treatment with multiple tuberculostatic therapy combined with multiple immunosuppressive agents, started at presentation or in the initial months after the first consultation, was shown to stop the progression of the disease, with a retained visual acuity of 1.0. One patient with macular involvement and a bilateral visual acuity of hand movements after 11 years of insufficient treatment, improved his visual acuity to 0.25 OD and 0.05 OS and presented a substantial visual field improvement that stabilized once multiple anti-tubercular and immunosuppressive therapy was introduced. Conclusion IGRA-positive serpiginous choroiditis (serpiginous-like choroiditis) could be halted by combined multiple tuberculostatic and multiple immunosuppressive agents, as seen in our study where 3/4 early treated patients had conserved central function and one late treated patient had recovered a substantial amount of visual field. In all 4 patients this treatment regimen halted the progression of the disease.

Tuberculosis Reactivation Demonstrated By Choroiditis And Inflammatory Choroidal Neovascular Membrane In A Patient Treated With Immune Checkpoint Inhibitors For Malignant Mucosal Melanoma

“…There is no consensus on the proper management of SLC. It can be di cult to manage due to poor RPE penetration with ATT and the requirement for prolonged immunosuppression to dampen the associated in ammatory response [15]. Fundal ndings and FFA imaging did not show activity in this lesion which was likely treated a number of years prior to this presentation with prolonged systemic medication.…”

“…This raised the index of suspicion for a TB related uveitis, potentially caused by ICPI induced reactivation of latent TB, which has been reported [14]. SLC is an immune-mediated in ammation of the choriocapillaris caused by Mycobacterium tuberculosis (Mtb) growth within the retinal pigment epithelium (RPE) [15]. There is no consensus on the proper management of SLC.…”

Tuberculosis reactivation demonstrated by choroiditis and inflammatory choroidal neovascular membrane in a patient treated with immune checkpoint inhibitors for malignant mucosal melanoma

“…This raised the index of suspicion for a TB related uveitis, potentially caused by ICPI induced reactivation of latent TB, which has been reported [ 15 ]. SLC is an immune-mediated inflammation of the choriocapillaris caused by Mycobacterium tuberculosis (Mtb) growth within the retinal pigment epithelium (RPE) [ 16 ]. Tubercular SLC can be difficult to manage due to poor RPE penetration with ATT and the requirement for prolonged immunosuppression to dampen the associated inflammatory response [ 16 ].…”

“…SLC is an immune-mediated inflammation of the choriocapillaris caused by Mycobacterium tuberculosis (Mtb) growth within the retinal pigment epithelium (RPE) [ 16 ]. Tubercular SLC can be difficult to manage due to poor RPE penetration with ATT and the requirement for prolonged immunosuppression to dampen the associated inflammatory response [ 16 ]. Fundal findings and FFA imaging did not show activity in this lesion which was likely treated a number of years prior to this presentation with prolonged systemic medication.…”

Benefits and Limitations of OCT-A in the Diagnosis and Follow-Up of Posterior Intraocular Inflammation in Current Clinical Practice: A Valuable Tool or a Deceiver?

“…However, studies only rarely suggested that OCT-A might play the role of a monitoring device, and those that hinted at this possibility indicated that further research was needed to standardize parameters to aid in uniform management and follow-up of cases [ 34 ]. In our hands, ICGA was still irreplaceable for global and precise assessment of lesions, often going beyond the vascular arcades, as well as for their follow-up and for monitoring the efficacy of therapeutical intervention, as shown in Figure 5 [ 35 ]. We also found that ICGA was more precise than OCT-A in showing subclinical lesions in SC [ 36 ].…”