Tuberculous optochiasmatic arachnoiditis

A 24-year-old woman developed multiple cerebral tuberculomas during treatment for central nervous system tuberculosis, requiring a protracted course of antituberculous therapy. Four years later, while on a second course of antituberculous therapy for relapsed disease, she developed deteriorating vision and further cerebral tuberculomas with inflammation; this was attributed to optochiasmatic arachnoiditis. She was treated at different stage with intravenous corticosteroids, second-line antituberculous therapy, infliximab and thalidomide. Her visual deficits initially improved but subsequently deteriorated despite escalating the anti-inflammatory medication. She died following severe sepsis. Optochiasmatic arachnoiditis threatens to cause irreversible complete blindness, but its best treatment is uncertain with no controlled trial data. We discuss the challenges of treating paradoxical reactions to antituberculous therapy and of treating optochiasmatic arachnoiditis.