Ocular disease in patients with TB and HIV presenting with fever in Malawi

To investigate ocular disease in Malawian patients with tuberculosis (TB) and HIV in presenting with fever, and to determine if indirect ophthalmoscopy is useful in the diagnosis of mycobacteraemia. A prospective study of all adult patients admitted with fever to Queen Elizabeth Central Hospital, Blantyre. All recruited patients had an ophthalmic examination, HIV tests, chest x-ray, sputum examinations, bacterial and mycobacterial blood cultures and malaria slide. 307 patients were recruited; 109 (36%) had TB, including 53 (17%) with mycobacteraemia; 255 (83%) had HIV and 191 (62%) had AIDS. Of the patients with TB 102 (94%) had HIV. Choroidal granulomas were found in four patients, all of whom had AIDS; three had disseminated TB with mycobacteraemia, and one had persistent fever but no other evidence of TB. Among the patients with AIDS, 32 (17%) had retinal microangiopathy manifest by cotton wool spots; one (0.5%) had signs of active cytomegalovirus (CMV) retinitis. The presence of microangiopathy was not related to TB. In Malawian patients with TB presenting acutely with fever, choroidal granulomas were found in 2.8%, and were concurrent with mycobacteraemia and AIDS. Ophthalmoscopy was not a useful aid in the diagnosis of mycobacteraemia. CMV retinitis is rarely seen in African AIDS patients. This may be due to mortality early in the disease course, or differences in race, HIV sub-type or co-morbidity.