Clinical considerations and treatment implications for immunosuppressed patients
| Clinical considerations | Treatment implications |
| The rates of disseminated/extra pulmonary TB rise as immunosuppression increases—seen in both HIV and anti-TNF-α treatment. Widespread haematogenous dissemination of TB (miliary disease) may be associated with multiple choroidal tubercules. | Increased risk of paradoxical reactions and immune reconstitution inflammatory syndromes during antiretroviral therapy, both intraocular (immune recovery uveitis) and systemic, leading to transient worsening of symptoms. |
| Other opportunistic infections, for example, Cytomegalovirus (CMV) retinitis, may coexist giving the potential for dual pathology or diagnostic uncertainty. | Increased rates of drug/drug interactions. Therapeutic drug monitoring may be appropriate if systemic disease affects drug absorption. |
| Immunological anergy may make some diagnostic tests (eg, IGRA, tuberculin skin test) less sensitive. Compromised cellular immunity can contribute to higher rates of subretinal abscess and panuveitis. | Lower threshold for treatment in suspicious cases, after thorough clinical assessment, imaging and microbiological sampling where appropriate. |
IGRA, interferon-gamma release-assays; TB, tuberculosis; TNF, tumour necrosis factor.