Reports of tuberculous panophthalmitis and/or orbital tuberculosis with or without orbital abscess are infrequent. As described in Table
1, many patients have either panophthalmitis or orbital infection, unlike our patient, who had extensive panophthalmitis and orbital abscesses despite 5 months of conventional ATT. Our patient’s presentation led to a high suspicion of drug-resistant tuberculosis. In a study done in China, researchers reported that the prevalence of any resistance to first-line drugs was 33.2% and that the prevalence of multidrug-resistant tuberculosis (MDR-TB) was 5.7% [
3]. Wilson and Tsukayama reported risk factors for the development and perpetuation of drug-resistant Mtb, as shown in Table
2 [
4]. Our patient had drug-susceptible Mtb; thus, drug resistance was not responsible for the poor treatment outcome in her case. Poor ATT compliance was likely the main causative factor. Directly observed treatment, short course (DOTS), especially with an individualized treatment regimen, is considered a successful method to improve cure rate and treatment completion in many centers [
5]; moreover, DOTS can also prevent the development of drug resistance [
6]. Statistical analysis to evaluate associated risk factors for developing tuberculous mycobacterial orbital abscess and/or panophthalmitis and visual prognosis has not been achievable, owing to the small number of cases in this patient population. For patients with HIV infection, debate continues regarding the ideal timing of HAART initiation and concomitant administration with ATT. The advantages of early HAART administration include higher cure rates, reduced risk of relapse, reduced risk of other HIV-associated opportunistic infections, and lower mortality rates. On the other hand, the disadvantages of early HAART initiation include potential drug interaction with rifampicin, thus limiting coadministration of selected protease inhibitors. This could result in cumulative toxicity, therapeutic failure, and risk of immune reconstitution inflammatory syndrome [
2,
7]. Our patient had not received HAART until almost 1 year after she was first diagnosed with EPTB infection.
Table 1
Reported cases of Mycobacterium tuberculosis panophthalmitis, orbital abscess, orbital tuberculoma, and orbital apex syndrome with wide varieties in age range, treatment outcomes, and visual prognosis
1 | 29 | F | Burmese | HIV | Panophthalmitis with orbital abscess | NPL | – | Subtotal exenteration | Our patient |
2 | 73 | M | N/A | Healthy | Panophthalmitis | 6/60 | – | Enucleation | |
3 | 14 | M | N/A | N/A | Panophthalmitis | N/A | N/A | N/A | |
4 | 59 | F | Indian | Healthy | Orbital tuberculoma | No visual loss | No visual loss | – | |
5 | 78 | F | African | Healthy | Orbital tuberculoma | No visual loss | No visual loss | Anterior orbitotomy | |
6 | 12 | F | N/A | N/A | Panophthalmitis | NPL | – | Enucleation | |
7 | 15 | F | Indian | N/A | Orbital abscess | 6/6 | 6/6 | Abscess drainage | |
8 | 86 | F | Caucasian | N/A | Orbital tuberculoma | Blind | Blind | – | |
9 | 6 | M | Indian | N/A | Orbital abscess | 6/6 | 6/6 | FNA | |
10 | 16 | F | Afro-Caribbean | N/A | Orbital apex syndrome | 6/190 | PL | – | |
11 | 7 | F | N/A | Healthy | Orbital abscess | 6/6 | N/A | Pus evacuation | |
12 | 29 | N/A | N/A | Healthy | Orbital mass | N/A | N/A | – | |
13 | 1 | N/A | Nigerian | N/A | Panophthalmitis | N/A | – | Enucleation | |
14 | 27 | M | Indian | HIV | Orbital abscess | NPL | NPL | – | |
Table 2
Risk factors for the development of drug resistance to
Mycobacterium tuberculosis as reported by Wilson and Tsukayama [
4]
Previous treatment for Mtb |
Prolonged hospitalization (in Mtb-endemic regions) |
human immunodeficiency virus coinfection |
Inappropriate prescribing of combination ATT (incorrect drug selection, dosing, and improper dispensing) |
Lack of directly observed therapy use during therapy and subsequent patient noncompliance with prescribed therapy |
Lack of sustainable drug availability to patients (for example, second-line drugs for drug-resistant tuberculosis) through an inadequate pharmaceutical supply chain or failure to provide free treatment |
Overuse of fluoroquinolones in other non-Mtb respiratory infection syndromes that propagates fluoroquinolone-resistant Mtb |
Delays in diagnosing drug-resistant Mtb |