Immune stromal keratitis: a rare ocular presentation of tuberculosis

An 11-year-old female patient presented with diminution of vision in both the eyes for the last 4 days. She had redness, watering and photophobia for the past 11 days. Slit lamp examination revealed multiple disc-shaped corneal stromal infiltrates with an overlying epithelial defect and hypopyon in both the eyes. A provisional diagnosis of infective keratitis was made. The patient was started on empirical antimicrobial therapy. However, no improvement was noted over the next 72 hours. Microbiological examination of the corneal scraping from both the eyes was negative. Considering the above, provisional diagnosis was changed to immune stromal keratouveitis and the patient was started on topical steroids. Further evaluation revealed a positive Mantoux test (30×20 mm) and contrast enhanced CT chest showing pulmonary nodules, suggestive of tuberculosis. The patient was subsequently started on antitubercular treatment. The infiltrates along with the ulcer and anterior uveitis responded dramatically to the revised treatment and resolved completely within 7 days of therapy.