Tubercular Optochiasmatic Arachnoiditis: A Case Report with Current Therapeutics and Management

Abstract Central nervous system tuberculosis (CNS TB) involves the brain parenchyma, meninges, and spinal cord. The primary pathology in CNS TB includes thick basal exudates leading to intense meningeal inflammation, vasculitis, and hydrocephalus. When these exudates and inflammation predominantly involve the structure in and around suprasellar cistern region, it results in a condition called optochiasmatic arachnoiditis (OCA). OCA is one of the cataclysmal complications of CNS TB, leading to vision loss. A previously healthy young woman came to our center with the complaints of low-grade fever, headache, weight loss, and visual obscuration. For further evaluation, she underwent lumbar puncture, and based on cerebrospinal fluid analysis, she was a diagnosed with CNS TB and was promptly started on antitubercular therapy along with steroid. A contrast-enhanced magnetic resonance imaging of the brain and orbit showed OCA. For OCA, she was given pulse-dose dexamethasone along with intrathecal hyaluronidase with which there was marginal improvement in vision. Management of OCA can be very challenging with unsatisfactory response. Many agents such as pulse steroid, intrathecal hyaluronidase, thalidomide, tumor necrosis factor alpha inhibitors, and cyclophosphamide have been used with inconsistent results. We have also done a review of the literature for the current evidence and newer therapeutics available for the management of OCA.