The Case: The family of a 49-year-old Chinese man brings him to the hospital after he becomes confused and disoriented. For about a week, the patient has had cough, cold symptoms, dizziness, and occasional vomiting. He is a recent immigrant and speaks no English. The examination questions are translated into Cantonese by a relative and by a translator phone.
The patient is oriented to person only but follows commands. Temperature is 38.9°C (102.1°F); blood pressure, 136/73 mm Hg; heart rate, 81 beats per minute; respiration rate, 22 breaths per minute; and oxygen saturation, 97% on room air. Pulmonary and cardiac findings are unremarkable. The abdomen is soft and nontender. There is no peripheral edema. Neurological findings are nonfocal. A chest radiograph obtained as part of a fever workup is shown.
To which diagnosis do the radiographic and clinical findings point?
• Legionella pneumonia
• Lymphangitic spread of cancer
• Miliary tuberculosis
(Answer and discussion begin on next page.)
1. Sharma SK, Mohan A, Sharma A, Mitra DK. Miliary tuberculosis: new insights into an old disease. Lancet Infect Dis. 2005;5:415-430.
2. Center for Disease Control and Prevention. Trends in tuberculosis—United States, 2005. MMWR. 2006;55:305-308.
3. Mert A, Ozaras R. Clinical importance of miliary pattern in the chest X-ray of a patient with fever of unknown origin. Intern Med. 2005;44:161.
4. Cain KP, Haley CA, Armstrong LR, et al. Tuberculosis among foreign-born persons in the United States: achieving tuberculosis elimination. Am J Respir Crit Care Med. 2007;175:75-79.
5. Sokolove PE, Rossman L, Cohen SH. The emergency department presentation of patients with active pulmonary tuberculosis. Acad Emerg Med. 2000;7:1056-1060.
6. Iannuzzi MC, Rybicki BA, Teirstein AS. Sarcoidosis. N Engl J Med. 2007;357:2153-2165.