In the article by Sarkisian and Lachs [1], the authors do not mention one of the most often overlooked and most readily corrected causes of failure to thrive in older adults: tuberculosis. Because we older people lived through a period of great prevalence of tuberculous infection, many of us retain viable organisms until death. In Arkansas, the incidence of active tuberculosis in persons older than 65 years of age is 10 times greater than the incidence in younger persons. A fact that is not commonly known is the twofold increase in the prevalence of positive tuberculin skin test results during the first 6 months in a nursing home. This increase is largely due to unperceived spread of Mycobacterium tuberculosis from a person with an unsuspected case of tuberculosis as a result of recrudescence of an ancient infection. Indeed, Eleanor Roosevelt's situation in her last year of life could have been described as "failure to thrive," but the autopsy showed disseminated tuberculosis [2]. The historic evidence strongly suggests that her initial infection occurred when she was 19 years of age and manifested as an idiopathic pleural effusion with spontaneous healing.

We have emphasized the importance of smoldering tuberculosis as a common phenomenon in nursing homes [3, 4]. However, of the total number of cases of tuberculosis in the elderly reported to the Arkansas Department of Health, only 20% occur in nursing home residents and 80% occur in persons living elsewhere. The fact that only 5% of the elderly live in nursing homes, however, means that the tuberculosis case rate in these institutions is four times the rate among the elderly in the general population. Thus, the risk for low-grade activity of an old tuberculous lesion is distinctly not limited to nursing home residents.