Disseminated Miliary Tuberculosis with Drug Resistance & Concomitant Syphilis & HIV Infections

Abstract

Background: Miliary TB is an aggressive infection in the setting of lymphohematogenous distribution of the bacilli of M. tuberculosis, that can be potentially fatal if left untreated. Drug-resistant TB may occur in the setting of patient non-compliance, concomitant HIV infection, inability to receive the correct duration and dose of medications, or patients in high-risk areas such as China or India. Methods: We describe a young immigrant patient who presented with electrolyte derangement and was found to have a complicated combination of infections including acute disseminated miliary TB, syphilis, and HIV. Our goal is to discuss this rare case and address risk factors associated with his immigrant status and barriers to treating these three serious infections together. Results: A 33 YO Hispanic M immigrant from Mexico with PMH of prior COVID-19 infection presented with cough, fever, and weakness. He was tachycardic and tachypneic with sufficient oxygen saturation on room air. Labs demonstrated hypoNa of 122mEq/dL (ref range 135-145) and he was admitted to the MICU for severe electrolyte derangement. CXR showed R lobe infiltrates. CT CAP suggestive of diffuse disseminated TB with severe PNA and several cavitary lesions involving the mediastinum. Sputum AFB cultures were positive. ID and Pulmonology teams were consulted and the patient began RIPE therapy. Admission was complicated by diagnoses of HIV and Syphilis. HAART therapy was deferred and the patient received Penicillin injections for Syphilis as well as prophylactic Bactrim DS (CD4 count 57). HypoNa improved and the patient was transferred to the floors. Despite >20d of RIPE therapy and the patient remaining asymptomatic, he remained AFB sputum culture positive, attributed to his concomitant HIV status or drug resistance. Conclusion: A high prevalence of HIV, syphilis, and TB exists in immigrant populations. It is imperative to screen for rapid diagnosis and management. Given high mortality rate of miliary TB, initiation of RIPE therapy is essential. Our patient’s HAART initiation was held to prevent immune reconstitution syndrome in the setting of multiple infections. There is limited randomized control trial data regarding optimal treatment guidelines and duration for patients with drug-resistant TB, especially with concomitant HIV.