Deputy Manager (Medical), Air India, New Delhi. Phlyctenular Conjunctivitis. Sumeet Singla*. JIACM 2010; 11(2): 127. A 40-year-old undernourished alcoholic ...
IMAGES IN CLINICAL MEDICINE
JIACM 2010; 11(2): 127
Phlyctenular Conjunctivitis Sumeet Singla* A 40-year-old undernourished alcoholic presented with a swelling on the right side of the neck, malaise, weight loss, and night sweats since 3 weeks. A non-tender, noninflamed, fluctuant swelling was palpable in the right posterior triangle of the neck (Fig. 1). Lungs were clear and no other nodes could be palpated. An ultrasound study of the neck showed matted lymph nodes with calcification and necrotic fluid inside. Mantoux test showed induration of 25 mm by 24 mm, and FNAC showed caseous material with acid-fast bacilli. HIV was non-reactive. Weightadjusted 5 drug ATT (HRZES) was prescribed. One week after starting ATT, he complained of intense irritation, redness, and watering from the left eye. Examination showed a whitish, raised nodule near the medial limbus with intense conjunctival inflammation (Fig. 2). A diagnosis of extrapulmonary tuberculosis with phlyctenular conjunctivitis was made and steroid and antihistaminic eye drops were added. The phlycten resolved after 2 weeks, without any residual scarring. Phlyctenular keratoconjunctivitis (PKC) is a type IV hypersensitivity response in the cornea and/or conjunctiva to a variety of distinct conditions, tuberculosis (evident or occult) being the commonest in India. Tuberculosis as an aetiological association is being supplanted by staphylococcal infection and worm infestation. In a study from Delhi1, tuberculosis was implicated in 77% (86/112) of all cases of PKC. Worm
Fig. 2: Left eye showing conjunctival phlycten near medial limbus.
infestation was found in 14 patients (12.4%), whereas 7 (6.2%) had staphylococcal blepharitis. Thirteen patients had evidence of multiple aetiologies, of which one causative factor was always tuberculosis. In this study, PKC lesions were observed to be more severe and recurrent in patients with tuberculosis. The most common underlying tubercular focus was found to be the lungs (56/86), followed by lymph nodes. Conjunctival phlyctens are usually transient and asymptomatic, but occasionally – in larger phlyctens – frank pustular conjunctivitis may develop with subsequent penetration into sclera, leading to permanent scar formation. Corneal phlyctens present with lacrimation, photophobia, and blepharospasm, and tend to leave opacities, leading to permanent vision impairment or occasionally blindness. A simple eye examination in all patients with tuberculosis will result in timely institution of local treatment for PKC and ameliorate the unwanted complications of visual disability.
Reference 1.
Fig. 1: Lump of cervical lymphadenopathy on right side of neck (arrow).
* Deputy Manager (Medical), Air India, New Delhi.
Singal A, Aggarwal P, Pandhi D, Rohatgi J. Cutaneous tuberculosis and phlyctenular keratoconjunctivitis: A forgotten association. Indian J Dermatol, Venereol, Leprol 2006; 72: 290-2.
