CASE REPORT MILIARY TUBERCULOSIS MASQUERADING AS PYREXIA OF OBSCURE ORIGIN: A CASE REPORT. AChijioke, A Aderibigbe, PM Kolo, TO Olanrewaju, ‘AM Makusidi and *AE Oguntoyin Departments of Medicine and “Radiology, University of llorin Teaching Hospital, PM.B. 1459, llorin, Kwara State, Nigeria ABSTRACT The diagnosis of miliary tuberculosis may be difficult as clinical features are often non-specific and plain chest radiograph may fail to reveal classical miliary shadows, even in endemic areas. A 48 year old immune competent male with pyrexia of obscure origin is presented. The diagnosis was made with the aid of computed tomogram of the chest as plain chest radiograph was apparently normal and sputum examination for alcohol acid fast bacilli was negative. He responded well to anti-tuberculosis drugs. The significance of imaging techniques in the diagnosis of this disease when routine conventional tests are unhelpful is emphasized. Keywords: Miliary tuberculosis, computed tomogram. INTRODUCTION Miliary tuberculosis is a form of tuberculosis resulting from widespread lymphohematogenous dissemination of mycobacterium tuberculosis from pulmonary or extra pulmonary focus’. It accounts for about 1-2% of all cases of tuberculosis and about 8% of all forms of extrapulmonary tuberculosis in immunocompetent. individuals.?° Many patients with the disease are immunocompromised and recognized risk factors include malnutrition old age, alcoholism, steroid and immunosuppresive drugs, silicosis, cancers, diabetes mellitus, human immunodeficiency virus (HIV) infection, chronic renal failure and organ transplantation’. Tuberculosis is a recognized infectious cause of pyrexia of obscure origin (POO) with high mortality rate”®. Mortality related to miliary tuberculosis in adults is about 25-30% and delay in diagnosis and/or commencement of treatment contribute to high mortality’. This paper reports a case of miliary tuberculosis masquerading as POO which was unmasked by treatment of superimposed bacterial septicaemic illness. CASE REPORT ‘A 48 year old male contractor, was referred from a private hospital with history of fever, cough and weight loss of four months duration and passage of loose stools in the preceding ten days. Fever was high grade and intermittent with associated chills and rigors. The cough was Correspondence: Dr A Chijioke Bakoko Post Office, P.O. Box 12945, Ilorin, Nigeria. Phone No. 234(+8056507210) E-mail: drchijiokeady@yahoo.com ‘Sahel Medical Journal, Vol. 13 No. 1, January-March, 2010 occasional and productive of yellowish mucoid sputum but was neither copious nor foul-smelling, twas not associated with haemoptysis. There was progressive weight loss, which became marked about three weeks prior to presentation. The stools were mucoid and non bloody. He had a history of painless swelling at the root of the neck which responded to @ course of azithromycin three years earlier. There was no history of contact with patient with chronic cough. The family, drug and social history and a review of other systems were not contributory. Examination revealed a chronically ill-looking and grossly wasted middle aged man. He was febrile (temp=39°c), mildly pale, jaundiced and had a grade 3 finger clubbing but no pedal oedema or significant lymph node enlargement. The liver was enlarged, firm, smooth surfaced and tender with a span of 16cm. The spleen was also enlarged by 4om below the left subcostal marginal. He had regular pulse rate of 110/min with BP of 120/80mmHg and normal heart sounds, His respiratory and central nervous systems were essentially normal. An initial impression of septicaemia with focus in the gastrointestinal tract was made. Disseminated tuberculosis and intra abdominal malignancy were suspected. He was commenced on ceftriaxone, metronidazole and gentamycin while undergoing further diagnostic screening. Investigations showed anaemia (packed cell volume = 28%), relative neutrophilia (WBC = 86 X 10% Neutrophils = 84% Lymphoytes = 14%), toxic granulation and elevated ESR(54mm fall in thour). Liver function tests showed a four-fold rise in AST and marginal rise of alkaline phosphatase, (60-52) 30Miliary Tuberculosis Masquerading as Pyrexia of Obscure Origin AChijioke, et al. with normal other parameters. HIV test was negative. The sputum, urine, blood and stool cultures yielded no growth and serial sputum Zeihl Neelson staining were negative for alcohol acid fast bacilli, Fasting blood sugar was 4.3mmollL. ‘Abdominal ultrasound revealed hepatosplenomegaly with uniform parenchymal echopattem without masses or focal lesions within its substance. There was no ascites or para aortic lymphadenopathy. His blood chemistry and urine analysis were normal. Plain chest x-ray was also normal (Fig !). y Showing the plain chest radiograph of the patient. Figure 4 On the 8" day of admission, the jaundice and hepatosplenomegaly had regressed while the patient continued to loose weight and had high grade continuous fever with spikes as high as 40°C. He became increasingly weak and dyspnoeic with effort intolerance. He had few crepitant rales in the lung bases. The possibilities of infection with atypical organisms, abscess collection in the chest or abdomen and/or internal malignancy were considered. A macrolide (azithromycin) was added to the medication through out the 2” week of admission without any sustained improvement in the high grade fever and he continued to loose weight . It was at this stage that computed tomogram (CT) of the chest and abdomen was requested and subsequently done ‘on the 20" day of admission because of ‘Sahel Medical Journal, Vol. 13 No. 1, January - March, 2010 financial constraints. The chest CT scan (Fig 2) showed wide spread miliary nodules while the abdominal CT revealed mild hepatomegaly without any focal parenchymal lesion. On the strength of the foregoing findings, a diagnosis of miliary tuberculosis was made and anti-tuberculosis drugs were started. He began to make steady clinical improvement and the fever gradually settled. He was discharged from the ward on the 48" day of anti tuberculosis drugs therapy and has continued to do well on subsequent follow-up visits, Figure 2 and 3: Showing chest CT scan of the patient at different levels. Discussion The clinical manifestations of miliary tuberculosis (MTB) are often non-specific and may include fever of several days duration, anorexia, weight loss, lassitude, cough, night (0-52) oTMiliary Tuberculosis Masquerading as Pyrexia of Obscure Origin AChijioke, et al. sweats, septic shock, fulminant hepatic failure, acute respiratory distress syndrome and multiple organ failure’. However, apyretic disease in which the patient present with progressive wasting, strongly suggestive of metastatic carcinoma (cryptic miliary tuberculosis) has been described’. Since MTB is a curable disease, with almost 100% mortality, if left untreated, it should always be included in the differential diagnosis list for pyrexia of obscure aetiology. This patient presented in a setting of POO. Tuberculosis is a common infectious cause of POO and it is associated with high mortality rate® Normal plain chest x-ray and sputum negativity for acid and alcohol fast bacilli in the case presented made the diagnosis of tuberculosis unlikely. The presence of military shadows in the CT- scan of the chest, strengthened the diagnosis of miliary tuberculosis and he was commenced on anti- tuberculosis drugs. This case illustrates the usefulness of computed tomogram, a modern imaging technique in the diagnosis of and avoidance of delayed treatment which is known to contribute significantly to high mortality rate.°"°"' Computed tomographic scan seems particularly useful in demonstrating smaller nodules that are not visualized through plain radiographs as in the case presented (fig.1), High-resolution CT scan can therefore improve the antemortem diagnosis of MTB. Contrast — enhanced CT scans and magnetic resonance imaging which are better in identifying extrapulmonary miliary lesions" were not utilized in the investigation of our patient. They would have been useful in identifying lesion in the liver and spleen, intraabdominal lymphadenopathy and even cold abscess missed by CT scan”. It is possible that this patient may have had miliary shadows in the intra abdominal organs which were not picked by the CT scan. The modem diagnostic imaging techniques are very few in most developing countries. The patient in this report certified most of the proposed criteria for the diagnosis of miliary tuberculosis. These include clinical presentation with pyrexia, anorexia, weight loss, miliary shadows on CT scan and response to anti tuberculosis treatment. In conclusion, computed tomogram scan is recommended in the diagnosis of military tuberculosis when there is high index of suspicion and routine diagnostic tools are unhelpful ‘Sahel Medical Journal, Vol. 13 No. 1, January-March, 2010 REFERENCES 1 10. "1 12. Baker SK and Gassroth J. Miliary tuberculosis In: WN ROM and SM Garay. Editors Tuberculosis. Lippincott Williams and Wilkins. Philadelphia. 2004; 427-444. CDC. Reported tuberculosis in the United states 2002. Tuberculosis (http://www.cdc.gov. nchstep/tb/surv/surv2002/pdfit23pdf) Accessed May 2004. Sharma SK and Mohan A. Extrapuimonary tuberculosis. Indian J. Med. Res. 2004; 120: 316-323. Mert A, Bilir M, Tabak F, Ozaras R, Ozturk R, et al. Miliary Tuberculosis: Clinical manifestation, diagnosis and outcome in 38 adults. Respirology 2001; 6: 217-224 Chin C, Lee SS, Chen YS, Wann SR, Lin WR, et al. Mycobacteriosis in patients with fever of unknown origin. J. Microbio. Immuno. Infect. 2003; 36: 248-253. Kim JH, Langston AA, Gallis H.A. Miliary tuberculosis: epidemiology, clinical manifestation, diagnosis and outcome. Rev. infect. Dis. 1990; 12: 583 - 590. Onadeko BO, Dickinson R and Sofowora EO. Miliary Tuberculosis of the lungs in Nigerian adults. E. Afr. Med, J. 1975; 52: 390-398, Zhang J and Handorf C. Miliary Tuberculosis presenting as acute respiratory distress syndrome, septic shock, DIC, and multiple organ failure. Tenn. Med. 2004; 97: 14-166. Yu YL, Chow WH, Humphries MJ, Wong RW and Gabriel M. Cryptic miliary tuberculosis. Q.J. Med. 1986; 59: 421-428. McGuinness G, Naidich DP, Jagitdar J, Leitman B and McCauley DI. High resolution CT findings in miliary lung disease. J ‘Compact. Assist. Tomogr 1992; 16: 384-390. YU RS, Zhang SZ, Wu JJ and Li RF. Imaging diagnosis of 12 patients with hepatic tuberculosis. World J. Gastroenterol 2004; 10: 1639-1642. Klaus ~ Dieter Lessnau, Cynthia de Luise, Miliary Tuberculosis.’ ___http://emedicine medscape com/article/221777-overview.2007 update, (60-52) 52