Intravitreal adalimumab for management of paradoxical worsening in tubercular serpiginous-like choroiditis – A case report

A 19-year-old Asian-Indian male presented with decreased vision in the right eye for 3 weeks. He had a prior history of choroiditis and steroid-induced glaucoma with advanced glaucomatous optic atrophy in the left eye. Fundus examination revealed active choroiditis lesions in the right eye and healed pigmented scars with total optic disc cupping in the left eye. The patient was diagnosed as tubercular serpiginous-like choroiditis (SLC) and started on standard four-drug anti-tubercular therapy. Two weeks later, he developed paradoxical worsening with the appearance of new lesions. Intravitreal methotrexate failed to control the inflammation, and intravitreal corticosteroids were contraindicated due to steroid responsiveness. A single intravitreal injection of adalimumab (1.5 mg/0.05 mL) was administered, resulting in rapid regression of active lesions and subsequent healing. This case demonstrates the potential of intravitreal adalimumab as an effective therapeutic option in managing paradoxical worsening in tubercular SLC unresponsive to standard treatment/steroid responsiveness.