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Case Report/Case Series |

Paradoxical Growth of Presumed Optochiasmatic Tuberculomas Following Medical Therapy

Mary Joseph, MS1; Teena M. Mendonca, MBBS1; Usha Vasu, MS, DNB1; Suneetha Nithyanandam, MS1; Thomas Mathew, MD, DM2
[+] Author Affiliations
1Department of Ophthalmology, St John’s Medical College, Bangalore, India
2Department of Neurology, St John’s Medical College, Bangalore, India
JAMA Ophthalmol. 2013;131(11):1463-1467. doi:10.1001/jamaophthalmol.2013.4840.
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Importance  Tuberculosis is an endemic infectious disease in developing countries. Patients receiving treatment for systemic tuberculosis may develop paradoxical growth of tuberculomas in the brain, which can lead to vision loss.

Observations  We describe 3 patients who had paradoxical development of tuberculomas in the anterior optic pathway during treatment for tuberculosis and presented with acute vision loss. These optochiasmatic tuberculomas were not present at the initial presentation of tuberculosis and appeared on brain magnetic resonance imaging at the time of presentation with vision loss. Vision improved on instituting systemic corticosteroids in addition to antituberculous treatment.

Conclusions and Relevance  As there was visual recovery after patients began receiving systemic corticosteroids and there was no worsening of the systemic condition, it is reasonable to assume that the optochiasmatic tuberculomas resulted from a paradoxical reaction. It is important to recognize this condition and initiate prompt treatment to reduce visual morbidity.

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Figures

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Figure 1.
Brain Magnetic Resonance Image of Patient 1 at Initial Diagnosis of Tuberculous Meningitis
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Figure 2.
Brain Magnetic Resonance Image of Patient 1 Showing Ring-Enhancing Lesions Suggestive of Optochiasmatic Tuberculomas
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Figure 3.
Visual Field of the Left Eye of Patient 1 During Presentation With Optic Neuropathy

GHT indicates glaucoma hemifield; MD, mean deviation; PSD, pattern standard deviation; and VFI, visual field index.

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Figure 4.
Visual Field of the Left Eye of Patient 1 After Resolution of Optic Neuropathy

GHT indicates glaucoma hemifield; MD, mean deviation; PSD, pattern standard deviation; and VFI, visual field index.

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Figure 5.
Visual Field of the Right Eye of Patient 1

GHT indicates glaucoma hemifield; MD, mean deviation; PSD, pattern standard deviation; and VFI, visual field index.

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Figure 6.
Brain Magnetic Resonance Image of Patient 2 Showing Parachiasmatic Tuberculomas
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Figure 7.
Brain Magnetic Resonance Image of Patient 3 Showing Ring-Enhancing Lesions in the Chiasmatic Region
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