Pulmonary Tuberculosis and SARS, China

To the Editor: A recent article by Chlebicki et al (1) described 4 patients hospitalized for dengue fever who were found to have retinal hemorrhages. These patients reported reduced visual acuity and metamor-phopsia, i.e., distorted visual images attributable to intrinsic retinal disease involving the macula; macular hemorrhages and exudates were found on retinal examination. The authors concluded that the retinal hemorrhages were responsible for the patients' visual symptoms. This conclusion is misleading because retinal hemorrhages alone cause scotomas. Rather, the accumulation of subretinal fluid in the macu-la results in metamorphopsia and blurring of vision. In previous reports of patients in whom macular changes developed from dengue fever, some were found to have macular hemorrhages (2–4). In addition, clinical examination and investigation of these patients showed vasculopatho-logic changes in the macular region that affected the retinal and choroidal blood vessels (5), although the tissues of the periphery tended to be spared. A fluorescein angiograph of the retina showed knobby hyperfluorescence of the retinal arterioles with minimal leakage, as well as some spots of leakage at the level of the retinal pigment epithelium. An indocyanine green angiograph showed diffuse hyperfluo-rescence of the choroid. These patho-logic changes in the macula were the most likely cause of the blurring of vision in such patients, which has been the case in our experience. The article by Chlebicki et al. did not state whether these procedures had been performed on their patients to confirm or exclude retinal or choroidal vasculopathy in the macula. Therefore, these authors would have had difficulty concluding that retinal hemorrhages caused blurring of vision and metamorphopsia in patients with dengue maculopathy. tourist with dengue fever and visual loss. To the Editor: As part of a cohort study of 83 patients with severe acute respiratory syndrome (SARS) in Beijing, China, we conducted a follow up study of all the patients by routine medical examination. During the process, 3 patients with chest radi-ographs consistent with active disease were identified as having pulmonary tuberculosis (TB). Here we describe the 1-year clinical outcome and immune response in these patients. Demographic details and coexist-ing conditions are shown in the Table. Patient 1 was a healthcare worker who became infected with SARS-associated coronavirus (CoV) while on duty with SARS patients. After he was transferred to a hospital dedicated to SARS management, pulmonary TB was diagnosed (positive acid-fast bacilli smear on sputum samples). Patients 2 and 3 were known …