Miliary TB

History
29 y Female Ethiopian Admitted To Medicine with 1/52 Fever , night sweating , diarrhea No contact with similar case No cough , SOB , Chest pain

History
Diarrhea non bloody 2-3 /day No jaundice , upper or lower GI bleeding

No dysphagia , odynophagia
No recent travel Pre immigration exam N

History
PMH : -ve No medication Non smoker & No ETOH

SR : decrease hearing & tinnitus

Examination
Febrile 38.5 BP 110/65 HR 95 RR 18 Sat 95% No lymphadenopathy , clubbing

Chest : clear , good breath sound

CVS : S1+S2+0 Abd : Mild diffuse tenderness No guarding , rigidity or rebound

Investigation
CBC : WBC 5 Lymph .3 Hb 65 MCV 69 RDW 16 Plt 85 PTT & INR N Na 133 K 3.2 Co2 16 Creat & BUN N

AST 160 , ALT 140 Alk Phos 60 Billirubin N

Hospital Course
Admitted to H4 for Hydration & work up CT Abdomen Multiple LN paraaortic , celiac Multiple nodules in spleen Thickening in small bowel & ascending colon CT guided Bx was planned

Hospital Course
Chest Medicine was consulted Increased SOB & O2 requirement O/E febrile 39.5 BP 100/55 HR 140 RR 22 Sat 93% on 7 l O2 Chest : Bilateral coarse crackles CVS: S1+S2+0 II /VI ESM LSB JVP 3 cm ASA

Hospital Course
CBC : Hb 65 CD4 25

ABG PH 7.38 PAO2 90 PCO2 30 Hco3 20 Blood ,sputum C/S ve Empiric Abx for ? Pneumonia Cefotaxime & azithromycine

Hospital Course
Anti TB Rx + Septra was started empirically BAL cytology , gram stain -ve +ve AFB CT guided LN Bx necrotizing granuloma

HIV +ve

Hospital Course
Clinical improvement within few days Worsening elevation liver enzyme & drop in Hb No evidence of hemolysis Required PRBC Tx

Hospital Course
Liver Bx non specific hepatitis ? Drug reaction Vs infectious Anti Tb Rx modified to INH , Rifabutin Gatifluxacin & ETB

Discharged with plan to start HAART Rx after treating TB

Miliary Tuberculosis
Used to be pathological then radiological term 1700 by John Jacobus Manget nodular surface of that look like Millet seeds Currently used denote all forms of progressive, widely disseminated hematogenous TB, even if the classical pathologic or radiologic findings are absent.

20% ot TB cases diagnosed postmortem in the pre antimicrobial era were miliary fallen to 0.7% after

Miliary Tuberculosis
Variable presentations from non specific symptoms to septic shock & ARDS Most common pulmonary manifestations SOB,cough ,chest pain ,crackles & hypoxemia Most common general symptoms fever ,wt loss , night sweating & malaise

Miliary Tuberculosis
Delayed & missed diagnosis is usually due to Non specific symptoms Lack of suspicion Delay in culturing all accessible body fluid Can arise progressive primary infection reactivation of a latent focus with spread rarely via iatrogenic origin.

Miliary Tuberculosis
Progressive primary disease After a local focus is established in the lung lymphatic then hematogenous dissemination with a predilection for spread to the most vascular organs, such as the liver, spleen, bone marrow and brain

Miliary Tuberculosis
Progressive primary disease Occurs when these distant foci fail to heal and is typically seen within the first six months after primary infection Many patients have underlying medical conditions impairing the development of effective cell mediated immunity

Miliary Tuberculosis
Reactivation of a latent focus Reactivation of latent focus of infection with subsequent erosion into adjoining lymphatics or blood vessels Commonly occurs years or decades after primary infection

Miliary Tuberculosis
Radiological Investigation CXR faint reticulonodular infiltrate Pleural reactions Hilar or mediastinal adenopath CT multiple small nodules septal thickening non specific