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Manfred Zierhut Centre of Ophthalmology University of Tuebingen, Germany

Retinal Vasculitis. Manfred Zierhut Centre of Ophthalmology University of Tuebingen, Germany. First Presentation – Ocular History June 2006. 43 year old African man OS: painful eye. First Presentation – General History. h ealthy. First Presentation – Ocular Examination OU.

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Manfred Zierhut Centre of Ophthalmology University of Tuebingen, Germany

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  1. Retinal Vasculitis Manfred Zierhut CentreofOphthalmology University of Tuebingen, Germany

  2. First Presentation – OcularHistoryJune2006 43 yearold African man OS: painfuleye

  3. First Presentation – General History healthy

  4. First Presentation – OcularExamination OU VA: 1.0/0.63 IOP: 18/48mmHg AC: 2+ cells, post. synechiae

  5. First Presentation – OcularExamination Fundus OU: massive vesselocclusion neovasc. oftheopticdisc smallgranuloma like changes

  6. First Presentation – Fundus OD

  7. First Presentation – FLA OD

  8. First Diagnosis Panuveitis with occlusive vasculitis ofunclearorigin

  9. First Presentation – Investigastions chest X-rayand CT: negativ ACE 34 (8-21) HIV, syphilis: negativ thalassemia ß+ (heterocygote) nosicklecellsdetectable

  10. First Presentation – First Treatment Corticosteroids syst. Lasercoagulation Mycophenolate mofetil Avastin Improvement of uveitis

  11. Follow up – First Treatment antiglaucomatous topicaldrugs corticosteroids syst. lasercoagulation

  12. Follow up – After 1 -3 Months improvementofinflammation, lesstheneovascularisation corticosteroids syst. continued lasercoagulation mycophenolate mofetil avastin

  13. Follow up – After 1 to 9 MonthsJuly 2006 to March 2007 neovascularizationof OD red. moreischemiaperipheral more AC cells, IOP increased systemiccorticosteroids, lasercoagulation avastin

  14. Follow Up – After 9 Months • inflammation reduced, but neovascularisation still detectable

  15. Follow Up – After 12 MonthsJune 2007 planned TNF-alpha blockingagents Quantiferon-test: positive

  16. Second Diagnosis panuveitis with occlusive vasculitis probablyof TB origin but noothersignsof TB detectable

  17. Follow Up – After 13 MonthsJuly 2007 PET-CT scan

  18. PET/CT-Scanner

  19. 1. Spiral CT CT 2. PET PET 3. Fusion Combinationof PET and CT

  20. PET-Tracer: FDG (Fluor-18-Desoxyglucosis) • inflammation • tumor „Trapping“

  21. SUV 2.4 PET/CT - Scan KM-CT Fusion PET+CT • enrichmentoftracer in paratracheal lymphnodes • followedbybiopsy

  22. ResultsofBiopsy PCR for TB: negative biopsy: non caseatinggranulomas diagnosis: Sarcoid plannedtherapy: TNF-alpha blockingagents

  23. Phone call after 3 weeks positive TB - culture

  24. Follow Up – After 16 MonthsOctober 2007 start anti-TB treatment

  25. Follow Up – Next MonthsOctober 2007 clinicallystablefindings regressionofneovascularisations occasionally intravitreal bleedings occasionally mild IOP increase

  26. Follow Up – After 22 MonthsApril 2008 back fromAfrica massive increaseofliverenzymes stopof anti-TB treatment due totoxicity

  27. Last Control– After 94 MonthsOctober 2014 VA: 1.0/0.9 IOP: 18/22 mmHg no AC cells, noneovascularisation treatment: topical anti-IOP drugs

  28. Change ofParadigm • TB: Infectiousdiseasecreatestheproblems • but mayinitiate an immune response which mayleadtouveitis • diagnosis: Chest-X-Ray, Mantoux • but in caseof strong suggestionof TB QuantiFERONand PET-CT-Scan with biopsyandculture • problem: immune-mediated (latent?) TB • probablyeverywhere

  29. Implications for Diagnosis • Tuberculosis: • PCR lesseffectiveasculture • specificityofquantiferontestmaybehigherthansuggested in theliterature • Sarcoidosis: • positive biopsynoprooveofsarcoid !! • inducedby TB?

  30. Implicationsfor TB-Treatment • infectious TB • anti TB-treatment • non-infectious (latent, immune-mediated) TB • anti-TB T-cellsexist (+ Quantiferon Test) • despite massive IS: nogeneralisation • anti-TB with immunosuppressives

  31. Immune-mediated TB TBAntigen Ag-Presentation Infectious TB T-Cells B-Cells Uveitis

  32. Conclusion • TB maymimicsarcoiduntilthelevelofbiopsy • infectiousandimmenumediated TB caninduce panuveitis with retinal vasculitis • treatmentconsistsof anti-TB-treatment andprobablyevenimmunosuppressivetreatment

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