Miliary Tuberculosis

Severe shortness of breath, a dry cough, and a 10-day history of fever sent a 37-year-old man with HIV disease to the emergency department. He complained of a poor appetite and had lost 10 lb over the last 10 days.

The white blood cell count was 2.0 × 103 /µL with an elevated monocyte count. His oxygen saturation was 85%. Physical findings included cyanosis of the lips and fingernail beds, tachypnea and tachycardia, severe cachexia, and altered mental status. Chest films revealed bilateral diffuse alveolar infiltrate.

Gopi Rana-Mukkavilli, MD of New York City treated this patient in the ICU, where he received oxygen and intravenous empiric treatment with ceftriaxone. His health continued to deteriorate over the next 2 days. A tuberculin skin test with purified protein derivative revealed an anergic state. Subsequent bronchoscopy with bronchoalveolar lavage showed acid-fast bacilli consistent with tuberculosis.

Miliary, or disseminated, tuberculosis is characterized by widely dispersed small tubercles that resemble millet seeds. Generally, a chest film will disclose these very small nodules of uniform size that are evenly distributed throughout both lung fields. Miliary tuberculosis almost always results from the discharge of infected caseous material into the bloodstream, usually from a well-hidden lymph node in the mediastinum.

The diagnosis often is missed because it is difficult to distinguish tuberculosis symptoms from those of other conditions that cause weight loss, fever, and fatigue. Miliary tuberculosis usually occurs in immunocompromised persons. The prognosis is poor unless treatment begins early.

Therapy is a 1-year course of ethambutol, rifampin, isoniazid, and pyrazinamide.

Once the diagnosis was made, this patient was moved to isolation and treatment with the four antituberculosis drugs and vitamin B6 was begun. Within 5 days, his oxygen saturation and chest film findings improved. The patient was discharged from the hospital, the antituberculosis agents were prescribed, and he was followed up with home visits.