Uveitis with occult choroiditis due to Mycobacterium kansasii: limitations of interferon-gamma release assay (IGRA) tests (case report and mini-review on ocular non-tuberculous mycobacteria and IGRA cross-reactivity)
Uveitis with occult choroiditis due to Mycobacterium kansasii: limitations of interferon-gamma release assay (IGRA) tests (case report and mini-review on ocular non-tuberculous mycobacteria and IGRA cross-reactivity)
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DOI：
10.1007/s10792-012-9588-3
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发表时间：
2012-10-01
影响因子：
1.6
通讯作者：
Herbort, Carl P.
中科院分区：
文献类型：
--
作者：
Kuznetcova, Tatiana I.;Sauty, Alain;Herbort, Carl P.
眼结核很难诊断，但当葡萄膜炎对炎症抑制治疗无效时应怀疑。干扰素-γ释放试验（IGRAs）对诊断疑似眼结核有很大帮助，特别是在非流行地区。吲哚菁绿色血管造影（ICGA）能够检测临床上无症状的脉络膜炎，当与阳性IGRA试验相关时，应导致临床医生怀疑眼结核，从而避免特定的治疗。IGRA检测也可以与一些非典型分支杆菌菌株发生反应，这一事实并不总是为人所知。我们在此报告一例术后炎症抵抗的病例，表现为ICGA检测到的隐性脉络膜炎和IGRA检测阳性，最可能是由于非结核分枝杆菌（NTM）堪萨斯分枝杆菌。一位66岁的男性在白内障和视网膜前膜联合手术后出现左眼顽固性黄斑囊样水肿（CMO）。入组时，他的最佳矫正视力（BCVA）为0.5远和近OS。通过激光闪光光度法测量的左眼（54.4 ph/ms）和右眼（50.9 ph/ms）的眼内炎症升高。4次Tenon皮下注射40 mg曲安西龙没有产生任何实质性的改善。因此，进行了完整的葡萄膜炎检查。眼底血管造影显示CMO OS，ICGA显示双眼脉络膜血管内有大量低荧光点和荧光团。在进行的实验室检查中，QuantiFERON（A（R））-TB Gold检测呈阳性。肺部检查显示右上叶浸润后，患者开始接受三联抗结核治疗。在支气管镜检查期间获得的支气管抽吸物为Ziehl阳性，培养物生长M。堪萨斯。9个月后，BCVA OS增加至1.0，耀斑降低至40.2 ph/ms。CMO OS通过血管造影消退，OCT检查未复发，黄斑仍轻微增厚。在罕见情况下，根据临床发现和阳性IGRA试验疑似眼结核可能是由于非典型分枝杆菌也产生阳性IGRA试验，如M。kansasii，M. szulgai，M. gordonae、黑脉叶蝉M. flavescens和M. marinum。在我们的病例中，未能分离出非典型分枝杆菌不会产生负面的治疗后果，因为M。kansasii是敏感的标准抗结核治疗，这是不是与其他非结核药物的情况。
Ocular tuberculosis is difficult to diagnose but should be suspected when uveitis fails to respond to inflammation suppressive therapy. Interferon-gamma release assays (IGRAs) represent a substantial help to diagnose suspected ocular tuberculosis especially in non-endemic areas. Indocyanine green angiography (ICGA) is able to detect clinically silent choroiditis that, when associated with a positive IGRA test, should lead the clinician to suspect ocular tuberculosis, warranting specific therapy. The fact that IGRA tests can also react with some atypical strains of mycobacteria is not always known. We report here a case with resistant post-operative inflammation that presented with occult ICGA-detected choroiditis and a positive IGRA test that was most probably due to the non-tuberculous mycobacterium (NTM) Mycobacterium kansasii. A 66 year-old man presented with a resistant cystoid macular oedema (CMO) in his left eye after combined cataract and epiretinal membrane surgery. At entry, his best-corrected visual acuity (BCVA) was 0.5 for far and near OS. Intraocular inflammation measured by laser flare photometry was elevated in the left eye (54.4 ph/ms) and also in the right eye (50.9 ph/ms). Four subTenon's injections of 40 mg of triamcinolone did not produce any substantial improvement. Therefore a complete uveitis work-up was performed. Fluorescein angiography showed CMO OS and ICGA showed numerous hypofluorescent dots and fuzziness of choroidal vessels in both eyes. Among performed laboratory tests, the QuantiFERON(A (R))-TB Gold test was positive. After a pulmonological examination disclosing a right upper lobe infiltrate, the patient was started on a triple anti-tuberculous therapy. Bronchial aspirate, obtained during bronchoscopy, was Ziehl-positive and culture grew M. kansasii. Nine months later, BCVA OS increased to 1.0 and flare decreased to 40.2 ph/ms. The CMO OS resolved angiographically and did not recur with a macula still slightly thickened on OCT. Suspected ocular tuberculosis based on clinical findings and a positive IGRA test can, in rare instances, be due to atypical mycobacteria that also produce positive IGRA tests such as M. kansasii, M. szulgai, M. gordonae, M. flavescens and M. marinum. In our case failure to isolate the atypical mycobacterium would not have had negative therapeutic consequences, as M. kansasii is sensitive to the standard anti-tuberculous treatments, which is not the case with other NTMs.