結核性ぶどう膜炎に結核性髄膜炎によるうっ血乳頭を併発した1例

A case of tuberculous uveitis accompanied by papilledema caused by tuberculous meningitis

要約　目的：結核性ぶどう膜炎に結核性髄膜炎によるうっ血乳頭を併発した1例を経験したため報告する。

症例：23歳，女性。1か月持続する頭痛と発熱をきっかけに名古屋医療センター脳神経内科を受診した。頭蓋内圧亢進を伴う髄膜炎，肺の多発粒状影，第4，5腰椎椎体破壊などを認め，気管支鏡検査にて結核菌が検出され粟粒結核と診断された。抗結核薬投与前に眼科を受診した。

所見：初診時の矯正視力は両眼ともに0.7，眼圧は右12mmHg，左10mmHg，両側の視神経乳頭腫脹と軽度の硝子体混濁所見を認めた。その後，抗結核薬投与により結核性髄膜炎は軽快し，1週間後の眼科再診時に視神経乳頭腫脹は改善しつつあったが，両側の硝子体混濁の悪化と硝子体出血が出現した。フルオレセイン蛍光眼底造影では，右眼の網膜新生血管と両側の網膜血管炎による蛍光漏出および無灌流領域を認め，経過から結核性ぶどう膜炎と診断した。両眼に汎網膜光凝固を施行し，約1か月後に硝子体出血は消退した。硝子体混濁はトリアムシノロンアセトニドテノン囊下注射により改善したが，矯正視力は右0.5，左0.3にとどまった。

結論：結核性ぶどう膜炎に結核性髄膜炎によるうっ血乳頭を併発した1例を経験したが，これまでに同様の症例の報告はなく稀な症例であると考えられた。結核による眼合併症は多岐にわたるため，眼以外の全身合併症の影響なども総合的に考慮して診断や治療を行う必要がある。

Abstract　Purpose：We report a rare case of tuberculous uveitis complicated by papilledema secondary to tuberculous meningitis.

Case：A 23-year-old woman presented to the Department of Neurology at Nagoya Medical Center with a one-month history of persistent headache and fever. Comprehensive examinations revealed meningitis with elevated intracranial pressure, multiple miliary infiltrates in the lungs, and destruction of the fourth and fifth lumbar vertebrae. Mycobacterium tuberculosis was detected on bronchoscopy, leading to a diagnosis of miliary tuberculosis. Before initiating anti-tuberculosis therapy, the patient was referred to the Department of Ophthalmology for evaluation.

Findings：At the initial ophthalmic examination, best-corrected visual acuity（BCVA） was 0.7 bilaterally, and intraocular pressure was 12 mmHg in the right eye and 10 mmHg in the left eye. Bilateral optic disc swelling and mild vitreous inflammation were observed. Following initiation of anti-tuberculosis therapy, the meningitis improved. One week later, the optic disc swelling resolved；however, bilateral vitreous hemorrhage and vitreous opacities developed. Fluorescein angiography revealed retinal neovascularization in the right eye, vascular leakage secondary to retinal vasculitis, and areas of non-perfusion in both eyes, confirming a diagnosis of tuberculous uveitis. Bilateral panretinal photocoagulation was performed, resulting in the resolution of vitreous hemorrhage within 1 month. Vitreous opacities improved following sub-Tenon's injection of triamcinolone acetonide, although BCVA remained 0.5 for the right eye and 0.3 for the left eye.

Conclusion：We encountered a rare case of tuberculous uveitis complicated by papilledema associated with tuberculous meningitis, to our knowledge, no similar cases have been reported to date. Since tuberculosis can manifest with a wide spectrum of ocular manifestations and management require careful consideration of systemic involvement.