A 63-year-old man was admitted to hospital for suppuration of his right eye in January 2017. He had MN history and had already been treated with glucocorticoids, tacrolimus, and tripterygium glycosides for 3 years. He stopped the drugs above following renal physicians' advice in August 2016. Ocular symptoms developed 2 months before admission and was diagnosed as conjunctivitis in an ophthalmology clinic. In spite of treatment with Levofloxacin eye drops, ocular symptoms became serious. Then an ulcer on the surface of the right sclera was found and biopsy was performed. The pathological diagnosis was granulomatous inflammation and inflammatory granulation tissue, with positive acid fast stain (Fig. 1), suggesting ocular TB.
Physical examination at presentation showed conjunctival congestion of the right eye, with an ulcer approximately 0.5 x 0.5 cm on the surface of the right sclera, which was confirmed by B-scan ultrasonography. He had normal blood pressure of 134/89 mmHg, with 97% saturation. Lymphadenopathy was absent. Pulmonary examination revealed left-sided low breath sound without rales. Pitting edema of both lower limbs was present. Computed tomography (CT) of the chest showed multiple tiny nodules distributed throughout both lungs and pleural fluid in the left pleural cavity (Fig. 2A and B). Laboratory examination showed erythrocyte sedimentation rate 104 mm/h (reference range, 0-15 mm/h) and C-reactive protein 30.68 mg/L (reference range <10 mg/L). 24-hour urinary protein excretion was 9016 mg (reference range, 0-150 mg). Blood chemistry revealed albumin 20 g/L (reference range, 35-55 g/L), with a mildly elevated creatinine and urea nitrogen. Although 3 separate smears of sputum for acid fast bacillus were negative, the polymerase chain reaction (PCR) detection of sputum for MTB was positive. Closed drainage of left pleural cavity was performed, draining cloudy and deep yellow liquid with total protein 21.2 g/L, adenosine deaminase (ADA) 60 U/L (reference range, 4-22 U/L), and gamma-interferon (gamma-IFN) >800 ng/L (reference range, 0-40 ng/L), suggesting tuberculous pleuritis. Bronchoscopy showed the dorsal segment of the left lower lobe was slightly narrow and bronchoalveolar lavage (BALF) was PCR positive for MTB. MTB cultures on samples from sputum, pleural effusion and BALF were all negative.
Antituberculous chemotherapy was begun with daily administrations of isoniazid (300 mg), ethambutol (750 mg), rifampin (450 mg), and pyrazinamide (1000 mg). After 2 weeks, the chest ultrasound and chest CT showed left pleural effusion had significantly reduced (Fig. 2C and D) and the left drainage tube was removed. However, the right pleural effusion emerged and closed drainage of the right pleural cavity was performed, draining cloudy and light yellow liquid, with total protein 10.9 g/L, ADA 32 U/L, and gamma-IFN >800 ng/L, suggesting tuberculous pleuritis with transudate. Antituberculous chemotherapy and closed drainage of the right pleural cavity were continued for another 10 days. However, the drainage volume of the right pleural cavity was not correspondingly reduced, about 200 to 400 mL every day. He refused the treatment with human albumin and prednison, and requested hospital discharge for poverty.
One month later, the patient came back. Blood chemistry showed albumin decreased to 13.9 g/L, while creatinine and urea nitrogen further elevated. 24-hour urinary protein excretion was elevated to 12,221 mg. He received administrations with tripterygium glycosides (60 mg/d), prednisone (30 mg/d), human albumin (10 g every other day), diuretics, and continuous antituberculous chemotherapy for 2 weeks. The patient's symptoms gradually improved. 24-hour urinary protein excretion decreased to 1844 mg. Chest ultrasound showed little encapsulated pleural effusion in the left pleural cavity while no pleural effusion on the right side. Three months after antituberculous chemotherapy, the right conjunctival congestion obviously relieved, and the ulcer of the right sclera decreased in size (about 0.3 x 0.3 cm) as well. The patient has been doing well so far.