Supplementary Material for: Recurrent episcleritis revealing pulmonary tuberculosis in an adolescent: a case report and literature review

Abstract
Background
Tuberculosis (TB) can affect the eye through direct infection or immune mechanisms. While ocular TB most often presents as uveitis or scleritis, episcleritis is an uncommon manifestation and can be mistaken for an idiopathic or autoimmune disease.
Case Presentation
A 17-year-old female patient presented at our hospital with recurrent episcleritis. The first two flare-ups were mild and responded well to conservative treatment; therefore, no further investigation was pursued at the time. However, during the third episode, routine baseline workup revealed a mildly elevated erythrocyte sedimentation rate with a normal chest radiograph (CXR). Given recurrence and a presumed immune-mediated process, she received topical steroids and low-dose methotrexate. Weeks later, she began experiencing fever and a persistent cough. On repeat CXR showed new left upper-lobe changes prompting computed tomography (CT) that revealed cavitary lesions. Bronchoalveolar lavage confirmed Mycobacterium tuberculosis. She was promptly switched to standard anti-tubercular therapy (ATT) showing systemic improvement, and without exhibiting additional episcleritis episodes
Conclusions
In TB-endemic settings, recurrent episcleritis warrants evaluation for TB before initiating or escalating immunosuppression. New systemic symptoms should prompt repeat chest imaging and microbiologic testing.