Unilateral Choroidal Granuloma and a Pupillary Abnormality in a Case of Miliary Tuberculosis: A Dilemma for the Physician

A young woman presented to the emergency with acute paraplegia and vision loss. She was diagnosed two months ago as a case of miliary tuberculosis with involvement of the chest and brain and therefore was on anti-tuberculosis treatment (ATT). She developed a decrease in vision and her treating physician suspecting optic neuropathy altered the regimen so as to omit Ethambutol and replaced it with Streptomycin. This treatment could not be continued with the advent of the COVID-19 pandemic as it required a hospital visit. On admission, she gave a history of inconsistent treatment and the ophthalmology evaluation showed decreased vision in the left eye, a relative afferent pupillary defect (RAPD), and a large solitary choroidal tubercle at the posterior pole of the same eye. The right eye was normal. On discussion with the treating physician, the standard four-drug ATT was reinstituted. Through our case report, we wish to highlight a challenging situation wherein the vision loss and pupillary abnormality with a background of ATT led to the change of treatment that would have required either daily hospital visits or other arrangements to be made to provide the same at home. This modified regimen not only proved to be challenging for the patient and caregivers but also may have played a role in the newer onset of further complications secondary to an irregular treatment regime.