A 31-year-old male-to-female transsexual prostitute, a recent immigrant from Mexico, came to the emergency department disoriented and with an elevated temperature. Medical history was notable for recent purified protein derivative positivity on skin testing. A chest x-ray film at examination showed fine miliary opacities in all lung fields (Figure 1). A computed tomographic scan of the head revealed prominent meningeal vascularity and multiple supratentorial and infratentorial enhancing lesions (Figure 2). A lumbar puncture specimen contained 618 white blood cells, of which 0.84 were neutrophils; 0.12, monocytes; and 0.04, lymphocytes. The diagnosis was presumed Mycobacterium tuberculosis infection and the patient was admitted for therapy with 4 drugs that included isoniazide, rifampin, ethambutol hydrochloride, and pyrizinimide. On the second hospital day, the ophthalmology service was asked to see the patient because of blurred vision of 2 months' duration. The patient was lethargic, with a best-corrected visual acuity of 20/40 in each eye. No afferent pupillary defect was present. External and anterior segment examination findings were normal. Fundus examination findings revealed multiple choroidal infiltrates involving the posterior pole in each eye (Figure 3, A, B). Serial fluorescein angiography showed early blockage and late staining of these lesions (Figure 3, C-G). Cultures from sputum and cerebrospinal fluid (Figure 4) grew M tuberculosis. The patient showed slow resolution of the multifocal choroiditis and improvement of mental status and visual acuity with continued treatment.
Chest x-ray film shows fine miliary opacities involving all lung fields.
Computed tomographic scan of the brain shows multiple enhancing lesions (arrows).
Color fundus photographs of the right (A) and left (B) eyes show bilateral, multifocal choroiditis (arrowheads). Serial fluorescein angiographic photographs (C-F) show early blocking hypofluorescence and late-staining hyperfluorescence corresponding to areas of choroidal infiltrate, as well as mild, late leakage from the optic nerve heads in each eye.
High-power, brightfield photomicrograph shows typical cording of Mycobacterium tuberculosis organisms grown in culture from cerebrospinal fluid (Kinyous acid-fast stain,original magnification ×400).
Mycobacterium tuberculosis is the most common infectious cause of death worldwide, accounting for almost 10 million fatalities per year.1 Recent immigrants to the United States appear to be at particularly high risk of infection.2 Tuberculous multifocal choroiditis, although uncommon, is well recognized,3 and can support the diagnosis of miliary, or disseminated, disease as was observed in our patient.
This study was supported in part by an unrestricted grant from Research to Prevent Blindness, Inc, New York, NY.
Corresponding author: Emmett T. Cunningham, Jr, MD, PhD, The Francis I. Proctor Foundation, University of California, San Francisco, School of Medicine, San Francisco, CA 94143-0944 (e-mail: email@example.com).
Grewal A, Kim RY, Cunningham ET. Miliary Tuberculosis. Arch Ophthalmol. 1998;116(7):953-954. doi: