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| CASE REPORT |
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| Year : 2023 | Volume
: 16
| Issue : 1 | Page : 139-141 |
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Bilateral disc edema: An unusual presentation of renal tuberculosis in a child
Biswajit Mishra1, Suchismita Mishra2, Yamijala Neha Srija2, Pradeep Kumar Panigrahi2
1 Department of Nephrology, Institute of Medical Sciences and SUM Hospital, Siksha O Anusandhan (Deemed to be University), Bhubaneswar, Odisha, India
2 Department of Ophthalmology, Institute of Medical Sciences and SUM Hospital, Siksha O Anusandhan (Deemed to be University), Bhubaneswar, Odisha, India
| Date of Submission | 09-Jan-2022 |
| Date of Decision | 13-May-2022 |
| Date of Acceptance | 02-Aug-2022 |
| Date of Web Publication | 21-Feb-2023 |
Correspondence Address:
Pradeep Kumar Panigrahi
Department of Ophthalmology, Institute of Medical Sciences and SUM Hospital, Siksha O Anusandhan (Deemed to be University), 8-Kalinga Nagar, Bhubaneswar - 751 003, Odisha
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ojo.ojo_12_22
 Abstract | | |
Renal tuberculosis (TB) is a rare clinical disorder in the pediatric population. A 15-year-old female presented with intermittent blurring of vision in both eyes associated with fever, abdominal pain, and weight loss. Fundus examination showed bilateral disc edema. Her blood pressure was 220/110 mmHg. Renal parameters were deranged with bilaterally enlarged kidneys. Renal biopsy was suggestive of epithelioid cell granuloma with Langhans type giant cells. The patient was diagnosed with as a case of refractory hypertension due to tubercular interstitial nephritis with bilateral Grade IV hypertensive retinopathy. She was started on antitubercular therapy and antihypertensives. There was a complete resolution of disc edema 2 months following initiation of therapy. Optic disc edema can be a presenting sign in renal TB. Early diagnosis and prompt referral can be associated with good visual and systemic outcomes.
Keywords: Bilateral, blood pressure, disc edema, renal tuberculosis, unusual
How to cite this article:
Mishra B, Mishra S, Srija YN, Panigrahi PK. Bilateral disc edema: An unusual presentation of renal tuberculosis in a child. Oman J Ophthalmol 2023;16:139-41 |
How to cite this URL:
Mishra B, Mishra S, Srija YN, Panigrahi PK. Bilateral disc edema: An unusual presentation of renal tuberculosis in a child. Oman J Ophthalmol [serial online] 2023 [cited 2023 Mar 26];16:139-41. Available from: https://www.ojoonline.org/text.asp?2023/16/1/139/370030 |
| Introduction | |  |
Hypertension in children has an incidence of approximately 1%–2%.[1] However, the prevalence of malignant hypertension is unknown but generally accepted to be extremely rare. Nonspecific features such as reduced consciousness level, seizures, headache, persistent vomiting, transient hemiparesis, and sixth nerve palsy are noted. Urinary tract tuberculosis (TB) is a rare clinical entity in children, representing <5% of pediatric extrapulmonary TB.[2] It is potentially underdiagnosed due to the nonspecific urinary tract symptoms. Systemic symptoms such as fever, weight loss, and decreased appetite are rarely complained of.[3]
Bilateral optic disc swelling as a single clinical sign in children can occur from several etiologies such as increased intracranial pressure, inflammation, infection, ischemia, or compression.[4],[5] Hypertension causes microvascular damage and thus plays an important role in the pathogenesis of chronic renal disease and retinopathy. Hence, urgent evaluation and strict control of blood pressure are required. We report an interesting case of renal TB who initially presented with ocular symptoms to the ophthalmology outpatient department.
| Case Report | | |
A 15-year-old girl presented to the ophthalmology department with complaints of headache and intermittent blurring of vision in both eyes for 1 month. She had intermittent fever at night associated with pain in the lower abdomen and significant weight loss for the past 2 months. On ocular examination, the best-corrected visual acuity was 20/20 and N-6 in both eyes. Color vision measured using Ishihara's chart was normal bilaterally. Anterior segment examination including pupillary reaction was normal bilaterally. Dilated fundoscopy revealed bilateral optic disc edema, with splinter hemorrhage near the optic disc in the left eye [Figure 1]a and [Figure 1]b. Perimetry (Humphrey Field Analyzer, SITA 30-2) showed an enlarged blind spot in both eyes. General examination revealed facial puffiness associated with pedal edema and tenderness on flanks. Her blood pressure was 220/110 mmHg. We referred the patient to the nephrology department. | Figure 1: (a) Color fundus photograph of the right eye showing disc edema. (b) Color fundus photograph of the left eye showing disc edema and splinter hemorrhage nasal to the optic disc (white arrow)
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Urine microscopy showed leukocyturia and proteinuria. Blood urea and serum creatinine levels were elevated. Salient laboratory investigations have been highlighted in [Table 1]. Bilaterally enlarged kidneys (right kidney −9.6 cm × 3.7 cm and left kidney −10.3 cm × 3.9 cm) were detected on the ultrasound abdomen. In view of bilateral swollen kidneys, obstructive pathology was reviewed but there was no upper tract stenosis. Hence, cystoscopy was planned which showed a partially duplicated pelvicalyceal system. Urine sample from the upper urinary tract was sent for culture and acid-fast bacilli (AFB) stain. CBNAAT was negative and urine bacterial culture showed no growth. As there was persistent subnephrotic proteinuria with active sediments, renal biopsy was done which was suggestive of epithelioid cell granuloma along with Langhans type of giant cell and caseous necrosis [Figure 2]. Chest radiography was normal. The Mantoux test was negative (an induration of 3 mm). In view of persistent papilledema in both eyes, neurology consultation was also done. Magnetic resonance imaging and magnetic resonance venography were normal. Cerebrospinal fluid opening pressure was normal (11 cmHg). | Figure 2: 40X light microscopic features of renal biopsy showing epithelioid cell granuloma (white arrow) with caseous necrosis (white star) and Langhans type giant cell (black arrow)
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Based on these clinical and laboratory findings, we diagnosed it as a case of refractory hypertension due to interstitial nephritis (TB) with bilateral Grade IV hypertensive retinopathy. The patient was started on antitubercular treatment (four-drug regimen) in the intensive phase along with antihypertensive medication (calcium channel blocker, angiotensin-converting enzyme inhibitor, and beta-blocker) and appropriate systemic antibiotic. After 2 months, there was a complete resolution of disc edema [Figure 3]a and [Figure 3]b. At 6 months, the patient was stable and on a single antihypertensive medication. Her renal parameters are normal (blood urea − 27 mg/dl and serum creatinine − 1.87 mg/dl) and she is constantly following up with the nephrologist. She can perform her daily activities well without any physical and psychological disturbances. | Figures 3: (a and b) Color fundus photograph of the right and left eyes 2 months following presentation showing complete resolution of disc edema
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| Discussion | | |
Urinary tract TB is one of the rare manifestations of Mycobacterium TB (MTB) infections.[2] The most common symptoms during the presentation are pain in the abdomen, waist, and lower back or difficulty in micturition.[3] Systemic symptoms such as fever, weight loss, and decreased appetite are rarely complained.[3] Urinalysis might show hematuria and pyuria. AFB can also be detected in urine. MTB is highly resistant to destruction. The bacteria duplicates in macrophages and are then carried in the circulation to different organs. The immune system inhibits the multiplication of bacteria in macrophage and results in granuloma formation. MTB that is locked in the periglomerular capillaries of the kidney can develop into macroscopic granuloma.[2] Some of them continue to enlarge and fill the nephrons forming the focus of infection in the kidney pyramid ultimately leading to the destruction of kidney parenchyma.
There is a long latent period (5–40 years) between the original pulmonary infection, and the appearance of clinical renal involvement is rare before the age of 20 years.[6] Our patient did not have any history of pulmonary TB in the past. However, there was history of contact with a TB patient 2 years ago. She presented with headache, intermittent blurring of vision, bilateral flank pain, and intermittent fever associated with loss of body weight. The elevated blood pressure in our patient can be due to recurrent urinary tract infections or activation of the rennin–angiotensin–aldosterone system. Severe visual dysfunction in malignant hypertension can be produced by the lack of therapy or by too-rapid reduction of hypertension.[7],[8],[9] Therefore, early diagnosis of malignant hypertension and adequate therapy is essential in reducing the likelihood of permanent severe visual and renal damage.
| Conclusion | | |
Optic disc edema can be one of the presenting signs in renal TB in the pediatric population. To the best of our knowledge, such a presentation has not been reported before. Proper ocular and systemic examination by the ophthalmologist can help in early diagnosis, appropriate referral, and treatment. In the pediatric age group, examination of blood pressure plays a pivotal role in optic disc edema evaluation similar to that of adult patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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| 4. | Daniels SR, Lipman MJ, Burke MJ, Loggie JM. The prevalence of retinal vascular abnormalities in children and adolescents with essential hypertension. Am J Ophthalmol 1991;111:205-8. |
| 5. | Lee AG, Beaver HA. Acute bilateral optic disk edema with a macular star figure in a 12-year-old girl. Surv Ophthalmol 2002;47:42-9. |
| 6. | Merchant SA. Tuberculosis of the genitourinary system. Indian J Radiol Imaging 1993;3:253-74. |
| 7. | Cove DH, Seddon M, Fletcher RF, Dukes DC. Blindness after treatment for malignant hypertension. Br Med J 1979;2:245-6. |
| 8. | Hulse JA, Taylor DS, Dillon MJ. Blindness and paraplegia in severe childhood hypertension. Lancet 1979;2:553-6. |
| 9. | Taylor D, Ramsay J, Day S, Dillon M. Infarction of the optic nerve head in children with accelerated hypertension. Br J Ophthalmol 1981;65:153-60. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1]
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