Sir,

We read with great interest the paper by Manousaridis et al,1 which adds to the publication by Sanghvi et al,2 with respect to presumed tuberculous (TB) uveitis in the United Kingdom, and we would commend both sets of authors for these well-presented case series. In the latter2 it was recommended that a full 6-month course of Anti-TB therapy (ATT) be commenced in all patients with uveitis and latent TB, in whom other causes of uveitis have been ruled out. We present a case of acute liver failure secondary to ATT in one such patient.

Case report

A 41-year-old Indian lady presented to Leicester Royal Infirmary Eye Casualty with gradual reduction in vision with floaters and was found to have bilateral granulomatous pan-uveitis. The best-corrected visual acuity was 6/36 in both eyes, and there were multiple choroidal tubercles (Figure 1) with leakage on fluorescein angiography. Quantiferon-TB gold testing was positive.

Figure 1
figure 1

Choroidal tubercles in both eyes.

Full size image

The Infectious Diseases Unit found no evidence of other active systemic TB and the patient was started on Rifater (rifampicin, isoniazid, pyrazinamide), Moxifloxacin 400 mg, and Pyridoxine 10 mg. After 28 days, the patient was admitted to a tertiary liver centre ITU with acute liver failure presumed secondary to ATT and subsequently developed severe autoimmune haemolysis presumed secondary to rifampicin. The ATT was stopped and the patient recovered. The patient declined any further ATT. The visual acuity at her last visit was 6/9 in each eye with low-dose topical steroid.

Comment

Hepatotoxicity is the most common iatrogenic disease in TB3 with an incidence between 1 and 10% worldwide,4, 5 and 4% in the United Kingdom.6 The benefits of ATT clearly outweigh the risks for active TB. However, this is not true in cases of latent TB and NICE guidance highlights those patient groups most likely to benefit from ATT.7 In the series of patients reported,1, 2 those who benefited most in terms of visual acuity from ATT had active TB and received systemic or periocular steroid. Furthermore, ATT may not be curative of the uveitis.3 We therefore recommend some caution when considering ATT in patients with presumed TB uveitis and latent TB.