A CASE OF MILIARY TB IN A YOUNG IMMUNOCOMPETENT FEMALE

Abstract

SESSION TITLE: Medical Student/Resident Lung Pathology SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Miliary tuberculosis (TB) refers to the hematogenous spread of Mycobacterium tuberculosis bacilli. It is a rare disease with only 2% of the 9,000 cases of tuberculosis reported annually accounting for miliary TB. Classically, it occurs in the lungs with radiologic findings of millet sized nodules scattered diffusely throughout the lung parenchyma. Miliary TB is usually only observed in young children or in severely immunocompromised adults, especially those with Human Immunodeficiency Virus (HIV). We present arare case of miliary TB in an immunocompetent adult female. CASE PRESENTATION: A 23-year-old Honduran born female with a past medical history of asthma presented to the hospital with symptoms of chest pain, shortness of breath, productive cough, fever and night sweats for two weeks duration. Of note, three months prior she had been admitted to the hospital with abdominal pain and diarrhea. CT of the abdomen and pelvis at that time demonstrated inflammation of the terminal ileum and sigmoid colon suspicious for enterocolitis. Bilateral peribronchial infiltrates were noted at the lung bases on CT of the abdomen and pelvis. A dedicated CT of the chest was performed which demonstrated scattered nodular densities bilaterally, some of which appeared cavitary. Antibiotics for pneumonia and enterocolitis were initiated and she was discharged home. Despite improvement in her diarrhea, she reported a 25 pound weight loss over the following months. A repeat CT of the chest was obtained on the current admission given her respiratory complaints. Worsening bilateral nodular infiltrates with enlargement of the cavitary lesions and bilateral hilar adenopathy highly suspicious of miliary tuberculosis was demonstrated. Sputum cultures were obtained with Mycobaterium tuberculosis complex isolated on all three acid fast bacillus (AFB) cultures. Rifampin, pyrazinamide, isoniazid and ethambutol (RIPE) were initiated along with pyridoxine (vitamin B6). Serology for HIV was negative and the patient was not on any immunosuppressant therapies. DISCUSSION: Misdiagnosis of miliary TB is common with up to 50% of cases discovered post mortem. Our case highlights that regardless of immune status, miliary TB should be considered in immigrants from tuberculosis endemic regions with pulmonary symptoms and radiologic findings of nodular densities with cavitation. Although not confirmed, our patient’s episode of enterocolitis may have been anextrapulmonary manifestation of tuberculosis involving the small bowel and colon. CONCLUSIONS: Disseminated TB usually occurs in the context of impaired cell mediated immunity, however, in the absence of HIV or immunosuppressive therapy as in our patient, the disease can occur in immunocompetent individuals. It is therefore imperative to maintain a high index of clinical suspicion in order to initiate antitubercular treatment in a timely manner to avoid morbidity and mortality. Reference #1: Global tuberculosis report 2019. Geneva: World Health Organization; 2019. License: CCBY-NC-SA3. 0IGO Reference #2: Ates Guler S, Bozkus F, Inci M, F, Kokoglu O, F, Ucmak H, Ozden S, Yuksel M: Evaluation of Pulmonary and Extrapulmonary Tuberculosis in Immunocompetent Adults: A Retrospective Case Series Analysis. Med Princ Pract 2015;24:75-79. doi: 10.1159/000365511 Reference #3: Pereira D, Sequeira T, Rocha S, Ferreira B (2015) Disseminated Tuberculosis in Immunocompetent Patients, Case Reports. J Infect Pulm Dis 1(1): doi http://dx.doi. org/10.16966/2470-3176.104 DISCLOSURES: No relevant relationships by Rhea Farquhar, source=Web Response No relevant relationships by Aileen Hocbo, source=Web Response No relevant relationships by Natalie Millet, source=Web Response No relevant relationships by Azka Sadiq, source=Web Response No relevant relationships by Sivashankar Sivaraman, source=Web Response