Tautologies and the Telltale Tubercle Bacillus

TB or not TB? That is the question. Tuberculosis remains an extremely common infection worldwide, with perhaps 30% of world’s population having been exposed to Mycobacteria tuberculosis. In a study 656 212 college freshmen in Zhengzhou, China, between 2004 and 2013, nearly 41% showed positive tuberculin skin test results.1Wang Y.-H. Tian Y. Gao J.-X. et al.Tuberculosis prevalence among university during 2004–2013.Afr Health Sci. 2018; 18: 1109-1116Crossref PubMed Scopus (3) Google Scholar United States, it estimated that 13 million people (approximately 4% population) show results for However, actual documented cases active tuberculosis are much rarer; 2018, 9025 were reported approximately 1 per 1400 patients (https://www.cdc.gov/tb/statistics/default.htm). Thus, endemic area, large fraction all uveitis will have results, but, likelihood, vast majority these coincident, causal. Further complicating management, treatment neither easy nor without risk. Full typically involves 9 months more 4-drug regimen significant potential side effects. Treatment patient’s may require use immunomodulators, which increase risk reactivation latent acceleration occult infection. Such issues would be tempered if we knew M. was eye causing inflammation. diagnosing elusive challenge. The ability detect infectious causes disease has made major advances thanks polymerase chain reaction-based metagenomic sequencing; using contemporary gene amplification techniques, infections could discovered by routine culture identified eye,2Doan T. Wilson M.R. Crawford E.D. al.Illuminating uveitis: deep sequencing identifies rare pathogens.Genome Med. 2016; 8: 90Crossref (94) Scholar,3Lee A.Y. Akileswaran L. Tibbetts M.D. al.Identification torque teno virus culture-negative endophthalmitis representational DNA sequencing.Ophthalmology. 2015; 122: 524-530Abstract Text PDF (61) brain,4Wilson Sample H.A. Zorn K.C. al.Clinical diagnosis meningitis encephalitis.N Engl J 2019; 380: 2327-2340Crossref (270) other tissues. But represents special challenge detection might limited sensitivity.5Chauhan H. Bansal R. Kumar A. al.Mycobacterium does evidence molecular human cadaveric ocular tissues setting.Clin Exp Ophthalmol. 2020; 48: 69-77Crossref (2) Indeed, one retrospective pathologic specimens suspected tubercular uveitis, paucity acid-fast bacteria observed (often only 2 frequently none), many negative reaction results.6Wroblewski K.J. Hidayat A.A. Neafie R.C. al.Ocular tuberculosis: clinicopathologic study.Ophthalmology. 2011; 118: 772-777Abstract (90) first cousin organism leprosy, Mycobacterium leprae. Leprosy well-recognized forms. lepromatous multibacillary form, damage from predominates. tuberculoid paucibacillary immune response Many leprosy fall into intermediate category dangles lepromatous. within almost certainly similar some forms like vasculitis known as Eales’ likely primarily resulting inciting presumably related itself. Adding great range manifestations eye, including scleritis, choroiditis, retinal vasculitis, anterior uveitis. Furthermore, our most often used tests diagnosis, interferon-γ assay blood, can but merely indicate exposure Finally, requires multiple antibiotics. This therapy acts relatively slowly, invariably successful, includes morbidity, trigger inflammation killing bacillus, thus response. While Bayesian analysis7Rosenbaum J.T. Wernick utility screening systemic lupus erythematosus A analysis.Arch 1990; 108: 1291-1293Crossref (64) provides means calculating likelihood patient particular given laboratory test, this method knowledge sensitivity specificity well being tested. Unfortunately, do gold standard true (i.e., caused eye), let alone distinguishing form.7Rosenbaum Lacking definitive disease, interpretation testing becomes highly problematic. Should everyone release treated tuberculosis? guidelines different versus nonendemic areas? Previous attempts at determining community consensus revealed very little agreement specialists terms diagnostic criteria approach treatment.8Lou S.M. Montgomery P.A. Larkin K.L. al.Diagnosis specialists: international perspective.Ocul Immunol Inflamm. 23: 32-39Crossref (27) Scholar,9Lou Winthrop K. al.Lack specialists.Ocul 25-31Crossref (29) regard, reports Agrawal al (see pages 266 277)10Agarwal Gunasekaran D.V. al.The Collaborative Ocular Study (COTS)-1 report 3: management global trends.Ocul 27: 465-473Crossref (33) Scholar, 11Agrawal Testi I. Mahajan S. al.Collaborative Consensus Guidelines on Management Tubercular Uveitis – Report 1: initiating antitubercular choroiditis.Ophthalmology. 2021; 128: 266-276Abstract (18) 12Agrawal Bodaghi B. 2: panuveitis, vasculitis.Ophthalmology. 277-287Abstract (13) representing (COTS) welcome contribution. These represent collective wisdom 81 experts who initially addressed than 400 questions vexing clinical problem. group came consensus. For example, radiographic consistent tuberculosis, should antituberculous therapy, either serpiginous choroiditis findings tuberculoma (even latter). strength did vary based whether area note, specifically rule out starting meet criteria; simply no reached regarding additional features warrant treatment. group’s recommendations impact because, least areas, effective markedly reduces recurrence.13Ang Hedayatfar Wong W. Chee S.P. Duration anti-tubercular associated case-control study.Br 2012; 96: 332-336Crossref (69) any expert consensus, devil details. posing question, lawyers, pollsters, doctors, detectives, others, know how question phrased absolutely critical. Asking treat choroidal asking same nodule choroid. As read current COTS, always confident initial vetted nuances such this, is, need avoid creating tautology itself: Would you Additionally, seem less clear scleritis. Despite reservation noted above, COTS step right direction. More better data needed establish evidence-based practice patterns treating Registries Intelligent Research Sight Registry well-designed trials help us resolve challenges optimal timing corticosteroid ideal number antibiotics prescribe area. resource reminder remain unanswered. formation working provide infrastructure much-needed randomized controlled future. Uveitis—Report Initiating Antitubercular Therapy Anterior Uveitis, Intermediate Panuveitis, Retinal VasculitisOphthalmologyVol. 128Issue 2PreviewThe (COTS), supported International Inflammation Society, Group, Foster Immunological set up international, expert-led project develop evidence- experience-based (TBU). Full-Text ChoroiditisOphthalmologyVol. 2PreviewAn initiative organized along Society systematically developed choroiditis. Re: al.: (Ophthalmology. 2021;128:266–276)OphthalmologyVol. 12PreviewWe article1 its commentary2 immense interest appreciate concerns highlighted Rosenbaum al2 solely immunologic tests. We add few comments.