a 33-year - old female was evaluated as part of an assessment for a 10-day pyrexia of unknown origin ( puo ) . she had undergone a successful renal transplant three years earlier and was on systemic immunosuppressants ( cyclosporine and oral prednisolone ) to prevent an organ rejection . systemically she was febrile ( 102 f ) but there were no other clinically significant findings . a routine chest x - ray showed nonspecific consolidation in both lung fields , which led to a differential diagnosis of tuberculosis , bacterial or viral pneumonia . her visual acuity was 20/30 in the right eye and 20/20 in the left eye . dilated fundoscopy of the right eye revealed multiple choroidal tubercles scattered throughout the postequatorial retina with one cluster along the superotemporal vessels and another in the perifoveal area [ fig . 1 ] the left eye showed two similar lesions in the macular area and three or four lesions in the inferior postequatorial retina [ fig . 2 ] . she was started on four - drug antitubercular therapy ( isoniazid 300 mg / day , ethambutol 800 mg / day , pyrazinamide 1gm / day and rifampicin 600 mg / day ) with resolution of her pyrexia and radiological evidence of healing within seven days . at this time partial resolution of tubercles a 62-year - old male patient was admitted with a two - day history of an acute onset high - grade fever with chills and rigors . he had undergone an uncomplicated renal allograft transplant for diabetic nephropathy one and a half years back . in the period prior to this illness he was taking mycophenolate mofetil ( 500 mg thrice daily ) and cyclosporine a ( 125 mg twice daily ) towards preventing an organ rejection . at the time of admission he was highly febrile , disoriented and prostrate . routine hemogram revealed mild anemia ( 9.3 g / dl ) , leucopenia ( 4000/mm ) and a high erythrocyte sedimentation rate of 71 mm at one hour . a chest x - ray showed ill - defined haziness in the right upper and midzones . a high - resolution chest tomogram ( hrct ) scan performed the following day , revealed patchy scattered areas of consolidation and ground glass appearance in both lung fields . the radiological findings suggested a differential diagnosis of tuberculosis , pneumocystis cariini pneumonia or a viral pneumonitis . the results of investigations for cytomegalovirus infection ( igg , igm ) , malaria ( peripheral smear ) and typhoid ( widal test ) were negative . an erythematous maculopapular rash was detected in his lower extremities , which was sent for biopsy . there were yellow - white choroidal lesions measuring 1/3 to 1/4 disc diameter in the posterior pole of either eye ( two in the right and one in the left ) consistent with choroidal tubercles . his condition rapidly deteriorated despite antitubercular therapy ( isoniazid 300 mg / day , ethambutol 800 mg / day , pyrazinamide 1gm / day and rifampicin 600 mg / day ) and he died on the seventh day post admission . a histopathological examination of the skin biopsy revealed a large number of acid - fast bacilli consistent with mycobacterium tuberculosis within the tissue . a 33-year - old female was evaluated as part of an assessment for a 10-day pyrexia of unknown origin ( puo ) . she had undergone a successful renal transplant three years earlier and was on systemic immunosuppressants ( cyclosporine and oral prednisolone ) to prevent an organ rejection . systemically she was febrile ( 102 f ) but there were no other clinically significant findings . a routine chest x - ray showed nonspecific consolidation in both lung fields , which led to a differential diagnosis of tuberculosis , bacterial or viral pneumonia . her visual acuity was 20/30 in the right eye and 20/20 in the left eye . dilated fundoscopy of the right eye revealed multiple choroidal tubercles scattered throughout the postequatorial retina with one cluster along the superotemporal vessels and another in the perifoveal area [ fig . 1 ] the left eye showed two similar lesions in the macular area and three or four lesions in the inferior postequatorial retina [ fig . 2 ] . she was started on four - drug antitubercular therapy ( isoniazid 300 mg / day , ethambutol 800 mg / day , pyrazinamide 1gm / day and rifampicin 600 mg / day ) with resolution of her pyrexia and radiological evidence of healing within seven days . at this time partial resolution of tubercles was noted . a 62-year - old male patient was admitted with a two - day history of an acute onset high - grade fever with chills and rigors . he had undergone an uncomplicated renal allograft transplant for diabetic nephropathy one and a half years back . in the period prior to this illness he was taking mycophenolate mofetil ( 500 mg thrice daily ) and cyclosporine a ( 125 mg twice daily ) towards preventing an organ rejection . at the time of admission he was highly febrile , disoriented and prostrate . routine hemogram revealed mild anemia ( 9.3 g / dl ) , leucopenia ( 4000/mm ) and a high erythrocyte sedimentation rate of 71 mm at one hour . a chest x - ray showed ill - defined haziness in the right upper and midzones . a high - resolution chest tomogram ( hrct ) scan performed the following day , revealed patchy scattered areas of consolidation and ground glass appearance in both lung fields . the radiological findings suggested a differential diagnosis of tuberculosis , pneumocystis cariini pneumonia or a viral pneumonitis . the results of investigations for cytomegalovirus infection ( igg , igm ) , malaria ( peripheral smear ) and typhoid ( widal test ) were negative . an erythematous maculopapular rash was detected in his lower extremities , which was sent for biopsy . there were yellow - white choroidal lesions measuring 1/3 to 1/4 disc diameter in the posterior pole of either eye ( two in the right and one in the left ) consistent with choroidal tubercles . his condition rapidly deteriorated despite antitubercular therapy ( isoniazid 300 mg / day , ethambutol 800 mg / day , pyrazinamide 1gm / day and rifampicin 600 mg / day ) and he died on the seventh day post admission . a histopathological examination of the skin biopsy revealed a large number of acid - fast bacilli consistent with mycobacterium tuberculosis within the tissue . chronic renal failure produces a state of immunosuppression due to uremia - induced changes in leukocyte function that reduce both acute and delayed inflammatory responses . patients on hemodialysis have disturbed leukocyte function due to the effects of the many bioincompatible dialysis membranes . the passage of blood through these membranes causes an inappropriate activation of complement and cytokine cascades with consequent defective immune responses.3   the use of potent immunosuppressives ( such as mycophenolate mofetil , cyclosporine a , azathioprine and glucocorticoids ) in posttransplant groups adds to the immunosuppression . the absence of fever or suspicious symptoms ( " silent " fashion ) presents a diagnostic dilemma . anergy to the mantoux test is common ( 32 to 40%).4,5   sputum microscopy and culture have low positive yields ( 11.1% cultures and 33.3% following polymerase chain reaction6 ) . additional invasive tests including bronchoalveolar lavage and analysis of pleural aspirate , gastric or peritoneal fluids and bone marrow specimens are often necessary . performed an invasive diagnostic procedure in 13 of 14 patients with posttransplant tuberculosis.7   apart from the cost and the surgical risk of these procedures , specimen analysis is often time - consuming . lui   et al . noted a mean time from the onset of symptoms to a specific diagnosis ( culture - based ) of 27  12 days.8   the delay in diagnosis may have therapeutic implications . patients with greater than five days of delay in identification of the cause of the pulmonary infiltrates had a three - fold greater risk of death than controls.9   several groups10,11   have suggested the use of composite indices consisting of lymphocyte subsets , t - cell proliferative responses in response to mitogens , neutrophil phagocytic capacity and reactive oxygen species ( ros ) generation that denote the degree of immunosuppression and consequent risk of infection . the use of these indices remains an area of future study . in a medline search we could identify only a single previous report12   suggesting the rarity of fundus examination rather than a low prevalence . both patients had pyrexia following an earlier allograft ( 18 and 36 months respectively ) with an ambiguous radiological and clinical picture . the detection of tubercles via the simple , noninvasive technique of fundoscopy confirmed diagnosis of systemic tuberculosis . the mantoux test was deferred in our patients due to severe underlying illness and the likelihood of pharmacological immunosuppression with consequent negative readings . in case 2 ,