A 23-year-old Malay gentleman factory worker presented with generalised headache for one-month duration. It was associated with nausea and vomiting. He experienced painless progressive blurring of vision of the right eye two weeks later which he described as inferior visual field defect. He had loss of appetite and significant reduced weight but no night sweats or hemoptysis. Otherwise, there was no history of contact with pulmonary tuberculosis patient, drug abuse, blood transfusion, and high-risk behaviour. He has no other medical illness.
His visual acuity on the right eye was 6/45 and improved to 6/15 with pinhole. There was no relative afferent pupillary defect. The right eye showed mild vitritis with no anterior chamber reaction. Right fundus examination revealed a choroidal raised lesion, yellowish in colour at the centre with pinkish fluffy edges, measuring one and a half disc diameter, and located at one disc diameter away from optic disc superiorly (Figure 1). The arcades vessels appeared tortuous and dilated with perivascular sheathing at supero- temporal and nasal arcade. The optic disc looked swollen and hyperaemic with gliosis at inferonasal disc margin. The left eye was normal.
Systemic examinations revealed no cervical, axillary, or inguinal lymphadenopathy. The respiratory, cardiovascular, and central nervous systems examination remained no abnormalities.
The ultrasonography of the right eye showed no evidence of retinal detachment, acoustic hollowing, or uveal excavation to suggest choroidal melanoma. The chest radiograph revealed no focal lesion or consolidation to suggest pulmonary tuberculosis. Mantoux test showed reading of 22 mm. Full blood count result showed that no significant finding with erythrocyte sedimentation rate (ESR) was 14 mm/h. Serum toxoplasmosis of IgM and IgG was negative. The syphilis and retroviral serology were nonreactive, and connective tissue results also inconclusive. The computerized tomography (CT) scan of the brain and orbit revealed multiple ill-defined peripherally enhancing iso to hypodense lesions with perilesional edema at right frontal and left temporal lobe consistent with cerebral abscesses (Figure 2).
A clinical diagnosis of right choroidal tuberculoma with multiple cerebral abscesses suggestive of tuberculosis infection was made. He was treated with antituberculosis chemotherapy for one year which divided into intensive phase for three months (tablet ethambutol 1200 mg daily, tablet pyrazinamide 1500 mg daily, tablet isoniazid 300 mg daily, tablet rifampicin 600 mg daily, and tablet vitamin B6 10 mg daily) and maintenance phase for nine months (tablet isoniazid 900 mg biweekly, tablet rifampicin 600 mg biweekly, and tablet vitamin B6 10 mg biweekly) by chest physician.
On follow-up, the repeated CT scan of the brain after three months of antituberculosis drugs showed resolved cerebral abscesses. At the same time, his right visual acuity was improved to 6/6 and choroidal tuberculoma of the right fundus appeared to have well-defined margin with adjacent retinal striae. At one-year follow-up, the choroidal tuberculoma resolved completely with scar formation and significant macular striae (Figure 3).