Tuberculosis and neuromyelitis optica spectrum disorder: A conundrum

Area of Science:

• Neurology
• Ophthalmology
• Infectious Diseases

Background:

• Atypical optic neuritis (AON) and Neuromyelitis Optica Spectrum Disorder (NMOSD) share overlapping symptoms, complicating diagnosis, particularly in pediatric cases.
• Negative anti-Aquaporin-4 antibody (AQP4-Ab) assays and co-existing tuberculosis (TB) can further obscure the diagnosis of the primary cause of neuritis.

Observation:

• Two pediatric cases presented with NMOSD features but did not meet diagnostic criteria, complicated by undiagnosed tuberculosis.
• One patient initially received an infectious optic neuropathy diagnosis, leading to delayed treatment and optic atrophy. The second patient presented with optic neuritis, longitudinal extensive transverse myelitis (LETM), and intracranial tuberculomas.

Findings:

• The presence of LETM in both cases raised suspicion for NMOSD, despite negative AQP4-Ab assays and concurrent tuberculosis.
• Diagnostic challenges in limited-resource settings highlight the need for careful clinical evaluation beyond serological markers.

Implications:

• Accurate and timely diagnosis of AON, especially when mimicking NMOSD with co-existing infections like TB, is critical for effective treatment.
• Prompt intervention in pediatric AON cases, particularly in resource-limited areas, can significantly improve visual outcomes and prevent irreversible damage.