Diagnosis Of Miliary Tuberculosis Research Articles

A 3-month-old child with miliary tuberculosis: a case report

Miliary tuberculosis (TB) is a severe form of disseminated TB that could be fatal without treatment. It remains a significant health problem in endemic countries such as Indonesia. A-3-month-old child was admitted to the hospital with chief complain of shortness of breath, cough, and intermittent low-grade fever. Significant clinical findings were lack of weight gain, previous contact with confirmed cases of TB, and severe malnutrition. Significant laboratory findings were anemia, elevated CRP, and hypoalbuminemia. Radiological findings were suggestive of miliary TB with bilateral diffuse reticulonodular lung lesion on chest CT-scan. Diagnosis of miliary TB is difficult because of nonspecific, atypical symptoms and varied clinical signs. It is needed multiple diagnostic approach, especially for children. Miliary TB remain to be a difficult case that require an early intervention despite difficulties in its diagnosis, to prevent morbidity and mortality of patient.

S2456 TB or Not TB? Miliary Tuberculosis in a QuantiFERON-Indeterminate Patient on Infliximab Therapy

Introduction: Miliary tuberculosis results from massive hematogenous dissemination of tuberculosis (TB) typically to the lung, bone, and less commonly to the gastrointestinal tract. It accounts for 2% of TB cases which may present as a life-threatening septic shock in the setting immunosuppression. Case Description/Methods: A 53-year-old Cuban male physician with moderate to severe ileocolic Crohn's disease and a history of travel to Cuba was recently initiated on Infliximab due to the failure of conventional therapy. Pretreatment Interferon-γ Release Assay (IGRA) QuantiFERON-TB Gold In-Tube, and tuberculin skin test were negative. Fourteen weeks later, he reported fever, emesis, and unintentional weight loss. Colonoscopy revealed severely inflamed mucosa of the right hemi-colon promoting escalation of infliximab dose with steroids for a presumed CD flare. Biopsy subsequently revealed numerous acid-fast bacilli. Therapy was immediately aborted, and he was then advised to initiate TB treatment. He returned eight days later with shock progressing to multiorgan failure. During emergent exploratory laparotomy, the small bowel and omentum were studded with white granulomatous nodules. He expired n the first postoperative day. Sputum, omentum, and abdominal wall cultures were all positive for Mycobacterium tuberculosis, and repeat IGRA was indeterminate. Discussion: Crohn’s disease (CD) is a chronic granulomatous inflammatory and destructive disease which follows a relapsing and remitting course. Infliximab therapy is initiated in moderate to severe stages however it carries with it an increased risk of reactivation of latent TB. IGRA testing before and during treatment is important during treatment with infliximab. It is difficult to surmise whether the subsequent hospital visits post infliximab initiation were due to worsening CD, or a manifestation of intestinal TB given the striking similarities. This patient’s insidious weight loss and rapid decline concomitant with the escalation of Infliximab and corticosteroid use points towards intestinal TB as the etiology of the symptoms. Despite the high sensitivity of IGRA testing, this patient’s travel history in an endemic area decreases the negative predictive value of the test. Diagnosis of miliary TB is challenging given its nonspecific presentation and limited diagnostic modalities. Therefore, patients continually exposed to endemic areas should prompt more frequent diagnostic re-evaluation prior to Infliximab escalation.

Acute miliary tuberculosis in pregnancy after in vitro fertilization and embryo transfer: a report of seven cases

BackgroundWhile miliary tuberculosis (TB) in pregnancy is rare after in vitro fertilization and embryo transfer (IVF-ET), it poses a serious threat to the health of pregnant women and their fetuses. The present study aimed to describe the clinical features of miliary TB and pregnancy outcomes of patients after IVF-ET.MethodsData of infertile patients who received IVF-ET at Peking University Third Hospital between January 2012 and December 2017 were retrospectively analyzed. Patients who developed miliary TB during pregnancy were identified, and clinical characteristics of miliary TB were described.ResultsOut of 62,755 infertile women enrolled, 7137 (11.4 %) showed signs of prior pulmonary TB on chest X-ray (CXR). Among the 15,136 women (mean age: 33.2 ± 5.0 years) who successfully achieved clinical pregnancy, seven patients aged 28–35 years had miliary TB during pregnancy, with two patients having a complication of TB meningitis. All these patients presented with fever. Notably, old TB lesions were detected on CXR in six patients before IVF-ET; nevertheless, no anti-TB therapy was administered. Furthermore, salpingography revealed oviduct obstruction in all patients (7/7). Patients received anti-TB therapy following a diagnosis of miliary TB and were clinically cured. However, pregnancy was terminated due to spontaneous (4/7) and induced (3/7) abortion.ConclusionsTB reactivation, mostly as miliary TB and TB meningitis, is severe in pregnant women after IVF-ET and deleterious to pregnancy outcomes. Signs of prior TB on CXR may be risk factors for TB reactivation during pregnancy.

Miliary tuberculosis: an atypical presentation

Miliary tuberculosis (TB) is a severe form of disseminated TB. In developing countries childhood miliary TB is a significant health problem. Pulmonary TB is the most common type of TB in children. Of all TB cases miliary TB accounts for about 1%. We report a case of paediatric miliary TB with acute presentation in a eleven years old female who presented with fever and cough since 3 days and rapid breathing since one day. Clinical examination showed hepatosplenomegaly, on auscultation chest was clear and air entry bilateral equal, chest x-ray was suggestive of miliary shadows suggestive of TB and it was confirmed by HRCT chest. Laboratory studies revealed anaemia and elevated erythrocyte sedimentation rate (ESR). Tuberculin test was negative, gastric lavage for acid-fast bacilli Gene-Xpert was positive for mycobacterium tuberculosis. Fundus examination revealed bilateral small, white sub retinal opacities with the classical appearance of choroidal tubercles. The diagnosis of Miliary TB was confirmed and the patient was started on anti TB therapy.

Paradoxical TBC with Tuberculomas and Tubercular Meningoencephalitis in a Pregnant Woman with (SARS-CoV-2)

A paradoxical response is a clinical or radiological deterioration of existing or new lesions in tuberculosis patients following treatment. Female gender, HIV infection, length of illness are all known potential risk factors. However, the likelihood of developing a paradoxical response with a concurrent infection of COVID-19 is scarcely reported in the literature, as the circumstance with our patient. In this report, we discuss the case of a 21-year-old woman, at 39 weeks gestation, who presented to the OPD with complaints of headache, coughing, nausea, and abdominal pain. RT-PCR was positive for COVID-19, and radiological imaging was consistent with the diagnosis of Miliary Tuberculosis, further complicated by tuberculous meningitis. Our study aims to highlight the paradox of TB progression in an obstetric patient with prior history of treated TB, coupled with the risk factors associated with a paradoxical reaction.

RAPID ONSET MILIARY TB: A MANIFESTATION OF IMMUNE RECONSTITUTION INFLAMMATORY SYNDROME

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Tuberculosis (TB) is now an uncommon entity in the United States, with an estimated incidence of 2.7 per 100,000 persons. (1) Infection with human immunodeficiency virus (HIV) is a significant risk factor for TB infection. The initiation of antiretroviral therapy (ART) may be associated with immune reconstitution inflammatory syndrome (IRIS), with the subsequent unmasking of previously subclinical infections, including TB. We present an uncommon case that dramatically presented with miliary TB shortly following the initiation of ART. CASE PRESENTATION: A 68-year-old female immigrant with a history depression, parkinson's disease, and known acquired immunodeficiency syndrome (AIDS)/HIV infection not treated for 6 years, presented with weakness, night sweats, and progressive dry cough for two weeks. She had been started on ART (bictegravir/emtricitabine/tenofovir) one month prior, with a pre-treatment viral load of 84,000 copy/mL, and CD4 count of 69 /µL. Physical examination at presentation revealed normal vital signs and bilateral rhonchi. Laboratory testing was notable for leukopenia (3.99 x10^6 /µL). Chest radiograph showed multiple bilateral nodules. Chest computed tomography (CT) revealed innumerable bilateral nodules, with mediastinal and axillary lymphadenopathy. (Fig 1) Three consecutive sputum samples were positive for acid fast bacilli. The diagnosis of miliary tuberculosis was made, and she was started on rifampin, isoniazid, ethambutol, and pyrazinamide (RIPE therapy), along with pyridoxine. Given the potential for drug interaction between rifampin and bictegravir, the latter was switched to dolutegravir for the duration of six planned months of antibiotic treatment. DISCUSSION: Paradoxical tuberculosis immune reconstitution inflammatory syndrome (TB-IRIS) is an early complication of antiretroviral therapy in patients with TB, that results from the rapid restoration of immune function, with a consequent exaggerated immune response, causing an exacerbation of pre-existing infections, or the unmasking of subclinical infections. TB-IRIS is characterized by severe localized or systemic inflammatory reactions against Mycobacterium tuberculosis antigens. One retrospective study showed an incidence of 8% in HIV and TB co-infected patients who were started on ART. (2) Our case notably had a dramatic presentation, with severe miliary TB on chest imaging, with no known history of TB. Additionally, chest radiography obtained merely one month prior to her presentation had been normal, demonstrating the rapidity with which miliary TB may develop following the initiation of ART. CONCLUSIONS: Patients with risk factors, such as immigration, should be monitored closed following the initiation of ART, for the manifestation of previously subclinical infections, such as TB. Reference #1: Schwartz, MD, Price SF, Pratt RH, et al. Tuberculosis - United States, 2019. MMWR Morb Mortal Wkly Rep. 2020;69:286-289 Reference #2: Kumarasamy N, Chaguturu S, Mayer KH, et al. Incidence of immune reconstitution syndrome in HIV/tuberculosis-coinfected patients after initiation of generic antiretroviral therapy in India. J Acquir Immune Defic Syndr. 2004 Dec 15;37(5):1574-6. DISCLOSURES: No relevant relationships by Rohan Kataria, source=Web Response No relevant relationships by Pius Ochieng, source=Web Response No relevant relationships by NISHANT SHARMA, source=Web Response No relevant relationships by Pandi Todhe, source=Web Response

Early diagnosis of miliary tuberculosis in a hemodialysis patient by combining two interferon-\u03b3-release assays: a case report

BackgroundPatients with end-stage renal disease undergoing chronic hemodialysis (HD) are at high risk to develop tuberculosis (TB) associated with a high mortality rate. TB diagnosis is often delayed due to non-specific symptoms, frequent extra-pulmonary manifestations, and rare microbiological confirmation. This case report illustrates the clear added value of combined interferon-γ -release assays (IGRA) in response to different mycobacterial antigens for an early diagnosis of TB in HD patients.Case presentationWe report the case of an Egyptian patient under chronic HD treatment, who presented with recurrent episodes of fever and myalgia of unknown origin, associated with an important inflammatory syndrome. These episodes resolved partially or completely within less than 1 month without any treatment but recurred 10 times within 3 years. Chest Computed Tomography and 18F-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (18FDG PET-CT) demonstrated several active mediastinal lymphadenopathies. TB was the first suspected diagnosis but cultures and polymerase chain reaction (PCR) remained negative on a mediastinal lymph node aspiration. In contrast, the results from two different IGRA performed on blood were highly suggestive of TB disease. Several granulomas, some of them with central non-caseating necrosis, were demonstrated on a pulmonary nodule obtained by thoracoscopic resection, but PCR and culture remained negative for M. tuberculosis. Three years after the initial symptoms, a new PET-CT revealed a retro-clavicular lymphadenopathy in addition to the mediastinal lymphadenopathies, and the M. tuberculosis culture performed on the resected lymphadenopathy was positive. Antibiotic treatment for TB was started and resulted in a clear improvement of the patient’s clinical condition, allowing him to successfully receive a renal graft.ConclusionsIn view of the high frequency of TB in patients undergoing chronic HD and of the limitations of the classical diagnosis procedures, nephrologists have to diagnose TB mostly on clinical suspicion. We demonstrate here that the use of a combined IGRA to two different mycobacterial antigens may significantly raise the index of suspicion and help clinicians to decide starting anti-TB treatment in HD patients.

Miliary tuberculosis presenting with acute respiratory distress syndrome in a patient with down syndrome

Introduction. Miliary tuberculosis (TB) is a rare and potentially fatal form of disseminated TB. It is caused by a widespread haematogenous dissemination of Mycobacterium tuberculosis from an active caseous focus to different organs. Sometimes it can have an acute presentation with a rapidonset clinical deterioration and death. Miliary TB complicated with an acute respiratory distress syndrome (ARDS) requiring mechanical ventilation (MV) is rare, even in countries with a high incidence of TB. Case report. A 35-yearold woman with Down syndrome (DS) was admitted to the Clinic for Pulmonology, Clinical Centre Kragujevac, due to an evaluation of cough and weight loss during last 2 months. Laboratory findings revealed anaemia, leukocytosis, elevated C-reactive protein (CRP) and hypoalbuminemia. A chest x-ray showed bilateral reticulonodular shadows, predominantly in the mid and lower right lung lobes. A purified protein derivative (PPD) skin test and induced sputum smear for acid-fast bacilli (AFB) were both negative. On the fifth day following admission, her health condition suddenly declined, and after developing a moderate ARDS, she was put on the mechanical ventilation. Due to a high clinical suspicion of miliary TB and the fact that her life was compromised, an empirical anti-tuberculosis therapy was initiated. Despite all therapeutic and supportive measures, the patient expired 3 days later. The diagnosis of miliary TB was established post-mortem. Conclusion. Miliary TB should be kept in mind in patients with DS due to immunosuppression associated with deficient cell-mediated immunity. The development of ARDS as a complication of miliary TB is difficult to identify due to a low causal association. High clinical suspicion and a chest radiograph with a typical appearance of miliary pattern justify the initiation of empirical anti-tuberculosis treatment in such patients, as an attempt to change poor prognosis.

Atypical cause of fever in advanced pregnancy

Although miliary tuberculosis (TB) is uncommon in pregnancy, it is difficult to diagnose when present and is often associated with a maternal history of intravenous drug abuse, malignancy, alcoholism, or human immunodeficiency virus (HIV) infection. TB in pregnancy can present with non-pulmonary symptoms, making the diagnosis and treatment challenging. We report a case of military TB in a lady with advanced pregnancy who presented with fever and cough without any history of exposure to TB patient. There was no history of alcoholism, intravenous drug abuse, or any other risk factors. Sputum for acid-fast bacilli stains and HIV screening were negative. The patient was started on anti-TB treatment after blood investigations ruled out other causes of fever and chest radiograph was suggestive of miliary TB. Confirming the diagnosis of miliary TB is an arduous process requiring a high index of suspicion. During pregnancy, histopathologic examination of tissue biopsy and GeneXpert may facilitate making an early diagnosis of extrapulmonary TB.

A case series of rituximab induced tuberculosis

Rituximab has a myriad of clinical uses, ranging from its disease modifying action in rheumatoid arthritis, to its role in chemotherapy for cancer. Being an anti CD20 monoclonal antibody, it controls inflammation by targeting peripheral B cells including those present in the synovium. The use of Rituximab is associated with some side effects such as cytopenias and increased risk of infections such as JC virus reactivation leading to multifocal encephalopathy. The role of Rituximab as an immunosuppressant has been established. However, its association with tuberculosis in endemic countries like India is yet to be understood well. The study was a cross sectional study of the two cases reported about the incidence of tuberculosis in patients receiving infusions of rituximab for rheumatoid diseases. These adverse drug reactions were reported to the nearest pharmacovigilance center through the Vigiflow portal of WHO and were assessed for their causality as per the WHO scale. A 45 year old male patient, a known case of Systemic Lupus Erythematosus, presented to a tertiary care hospital with high grade fever with chills and rigors after which he was diagnosed with pleural effusion due to tuberculosis. The patient was on immunosuppressants which included Rituximab, Mycophenolate Sodium, Prednisolone and Hydroxychloroquine. Rituximab was withdrawn and the remaining medications were continued as per the initial plan. A 19 year old male patient, a known case of dermatomyositis and dilated cardiomyopathy, presented to a tertiary care hospital with complaints of fever with chills and rigors, and breathlessness on exertion which was followed by the diagnosis of miliary tuberculosis. Earlier, the patient was on Rituximab, Cyclophosphamide, Hydroxychloroquine and Prednisolone. Plan of further infusions of Rituximab and Cyclophosphamide was terminated while the remaining medications were continued. Both the patients were put on anti tubercular therapy and are now improving. The association of bacterial infections like tuberculosis with the use of Rituximab is not well understood. However, Rituximab being an immunosuppressant can be considered to be related to this infection. In our case series we readdress this association through a literature review.

The Isambert disease: a very rare revelation of miliary tuberculosis

The objective of this study was to report a case of miliary tuberculosis revealed by a pharyngeal localization, and study this disease through a literature review.We report the clinical case of a 23 year old patient presented for chronic tonsillitis treated as bacterial but without improvement. Dysphonia and dysphagia were added later with the same signs of tuberculous impregnation. The chest x-ray done before the onset of coughing had objectified miliary. The diagnosis of tuberculosis was selected before the detection of acid-fast bacilli in cytobacteriological examination of the pharyngeal swab and sputum. Specific antituberculous treatment led to a favourable outcomeIn a context of endemic tuberculosis, the diagnosis of miliary tuberculosis of the pharynxshould be considered in all pharyngeal syndrome did not improve with medical treatment.Keywords: Isambert disease; oropharynx ; tuberculosis

Newly recognized cerebral infarctions on postmortem imaging: a report of three cases with systemic infectious disease

BackgroundPostmortem imaging (PMI) refers to the imaging of cadavers by computed tomography (CT) and/or magnetic resonance imaging (MRI). Three cases of cerebral infarctions that were not found during life but were newly recognized on PMI and were associated with severe systemic infections are presented.Case presentationsAn 81-year-old woman with a pacemaker and slightly impaired liver function presented with fever. Imaging suggested interstitial pneumonia and an iliopsoas abscess, and blood tests showed liver dysfunction and disseminated intravascular coagulation (DIC). Despite three-agent combined therapy for tuberculosis, she died 32 days after hospitalization. PMI showed multiple fresh cerebral and cerebellar infarctions and diffuse ground-glass shadows in bilateral lungs. On autopsy, the diagnosis of miliary tuberculosis was made, and non-bacterial thrombotic endocarditis that involved the aortic valve may have caused the cerebral infarctions.A 74-year-old man on steroid therapy for systemic lupus erythematosus presented with severe anemia, melena with no obvious source, and DIC. Imaging suggested intestinal perforation. The patient was treated with antibiotics and drainage of ascites. However, he developed adult respiratory distress syndrome, worsening DIC, and renal dysfunction and died 2 months after admission. PMI showed infiltrative lung shadow, ascites, an abdominal aortic aneurysm, a wide infarction in the right parietal lobe, and multiple new cerebral infarctions. Autopsy examination showed purulent ascites, diffuse peritonitis, invasive bronchopulmonary aspergillosis, and non-bacterial thrombotic endocarditis that likely caused the cerebral infarctions.A 65-year-old man with an old pontine infarction presented with a fever and neutropenia. Despite appropriate treatment, his fever persisted. CT showed bilateral upper lobe pneumonia, pain appeared in both femoral regions, and intramuscular abscesses of both shoulders developed. His pneumonia worsened, his level of consciousness decreased, right hemiplegia developed, and he died. PMI showed a newly diagnosed cerebral infarction in the left parietal lobe. The autopsy revealed bilateral bronchopneumonia, right-sided pleuritis with effusion, an intramuscular abscess in the right thigh, and fresh multiple organ infarctions. Systemic fibrin thrombosis and DIC were also found. Postmortem cultures showed E. coli and Burkholderia cepacia.ConclusionCerebral infarction that is newly recognized on PMI might suggest the presence of severe systemic infection.

High Detection Rates of Urine Mycobacterium tuberculosis in Patients with Suspected Miliary Tuberculosis.

Objective The utility of detecting Mycobacterium tuberculosis in urine samples from patients with pulmonary tuberculous with diffuse small nodular shadows (suspected miliary tuberculosis (MTB)) is still unclear in Japan. A retrospective cross-sectional study was conducted to investigate the detection rates of M. tuberculosis in urine of patients with suspected MTB. Methods Among 687 hospitalized patients with tuberculosis, 45 with culture-confirmed suspected MTB and the data of culture and polymerase chain reaction (PCR) for M. tuberculosis in urine and sputum samples were investigated. The detection rates of M. tuberculosis in urine using cultures and PCR were calculated. The detection rate of urine was then compared with that of bone marrow aspiration. Results Fourteen patients with suspected MTB were ultimately analyzed. A diagnosis of miliary tuberculosis was suspected in all patients before anti-tuberculosis chemotherapy. Positive results by PCR (11 [78.6%] cases) and culture (8 [57.1%]) were obtained from urine samples. In patients with suspected MTB, there was no significant difference in the detection rates between M. tuberculosis in urine using a combination of PCR and culture (85.6% [12/14 cases]) and bone marrow aspiration (66.7% [8/12 cases]) (p>0.05). Conclusion Using PCR and culture, we demonstrated high detection rates of M. tuberculosis in the urine of patients with suspected MTB. A combination of PCR and culture compared favorably with the detection rates achieved with bone marrow aspiration. We believe that detection of M. tuberculosis from urine and sputum samples may be easy and safe for patients with disseminated tuberculosis infections such as definitive MTB.

A young female with miliary mottling in her chest X-ray

The presence of miliary nodular shadows in the chest radiograph although points to the classical diagnosis of miliary tuberculosis in endemic areas, persistence of these shadows on treatment and the disease presentation may alter the diagnosis. The combination of miliary mottling on chest radiograph along with the high-resolution computed tomography appearance of crazy-paving pattern with calcifications along the interlobular septa in the correct clinical context is considered diagnostic of pulmonary alveolar microlithiasis (PAM). The combination of above radiological features in one such case is presented here where histopathological examination of the lung proved the diagnosis of PAM.

Refractory Isoniazid-Resistant Miliary TB or Something More?

SESSION TITLE: Fellow Case Report Poster - Chest Infections II SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Miliary nodular pattern is defined by diffuse and symmetrically distributed micronodules (<3mm) within the lungs, and often pedagogically associated with hematogenously disseminated tuberculosis (TB). However, the differential is broader. CASE PRESENTATION: 57-year-old Chinese man, former smoker, with chronic HBV, history of incompletely treated pulmonary TB in 1996 presented with progressive dry cough, dyspnea, weight loss, fevers, chills, and night sweats. Chest x-ray showed bilateral diffuse nodularity, and sputum culture grew Mycobacterium tuberculosis. He was started on IRPE for miliary TB. Course was complicated by asymptomatic liver transaminitis requiring treatment discontinuation after 3 weeks. IRE/Levofloxacin were substituted. He was admitted to the hospital for worsening dyspnea and cough with concern for possible resistance. The original sputum culture revealed INH resistance but susceptibility to other first line agents, and he was discharged on RPE/Moxifloxacin. He was readmitted for medication noncompliance and new hypoxia. CT chest showed persistent diffuse pulmonary nodules, biapical scarring and emphysema. Liver biopsy showed concern for drug-induced versus autoimmune hepatitis, and he was started on prednisone and tenofovir, as well as a liver-sparing regimen of amikacin, ethambutol and moxifloxacin. He continued to worsen. Open lung biopsy of two different lobes revealed lung adenocarcinoma in both surgical specimens. DISCUSSION: The differential diagnosis of miliary pattern on chest imaging includes TB, metastatic disease, fungal infections, sarcoidosis, and pneumoconioses. Unlike miliary TB (micronodules ranging from 1 to 3mm), miliary metastatic lesions may have variable sizes (up to 1cm). Although this case had a number of reasons to anchor on a diagnosis of miliary TB, it is important to keep a broader differential for miliary pattern, and re-think the diagnosis when patients are not improving on appropriate therapy. CONCLUSIONS: We report a case of advanced stage lung adenocarcinoma appearing in a miliary nodular pattern in the setting of concurrent tuberculosis. Patients with diffuse miliary nodules, especially for those whose symptoms do not improve after tuberculosis treatment, should be evaluated for other diagnoses, such as cancer. Reference #1: Oikonomou, A et al. Mimics in chest disease: interstitial opacities. Insights Imaging. 2013;4:9-27. DISCLOSURE: The following authors have nothing to disclose: Kathleen Doo, Deepak Pradhan No Product/Research Disclosure Information

Miliary Tuberculosis as a Cause of Sudden Death in a Patient Misdiagnosed With Depression

Introduction Today, miliary spread remains one of the world's most lethal infectious diseases. Despite the availability of effective treatment for most cases, it is still a cause of death in our environment. Some cases of active tuberculosis (TB) are not identified until the patient is dead and an autopsy has been performed. We report an autopsy case of miliary TB and discuss the mechanism of death. Case Report N.M. is a 24-year-old woman without any relevant personal medical or family history. She was admitted with fever of 40 days' duration. The fever was irregular, higher at nights, and associated with headache and anorexia. The patient did not give any history of coughing, hemoptysis, sore throat, joint pains, skin rash, abdominal pain, or rheumatic heart disease. The examination and the radiological investigations did not show any abnormalities. The patient was symptomatically medicated and allowed to return home. After 1 week, she was discovered dead in her bed. A forensic autopsy was requested. At necropsy, the lungs, liver, spleen, and kidneys were macroscopically palish, heterogeneous, and dotted with myriad of small seeds (1–2 mm). Mesentery was the seat of a large firm mass, adhering to the intestinal walls and the pancreas. The diagnosis of miliary TB was confirmed by histological examination. The toxicological screening was negative. Conclusions Our case highlights a rare but important complication of TB, which is “TB-related sudden death.” There is a need for more awareness of the disease, especially in the light of recent reports showing a growing incidence of extrapulmonary TB.

Miliary tuberculosis characterised by lipomembranous fat necrosis

Figure: Miliary tuberculosis (A) Lipomembranous fat necrosis at 200× magnifi cation. (B) Ulceration and poor healing several months after the initial cellulitis-like presentation. A 29-year-old Dominican woman on chronic prednisone therapy because of a history of Lofgren’s syndrome presented with recurrent fevers, pleuritic chest pain, and joint swelling. Examination revealed diff use synovitis and notable swelling and erythema of the right elbow. MRI of her right elbow showed diff use signal intensity in the subcutaneous fat and superfi cial myofascial planes consistent with cellulitis. A chest CT scan showed several small lung nodules. After mild improvement with intravenous antibiotics, she was discharged on oral antibiotics. She returned 2 weeks later with high fever, nausea, vomiting, and no improvement of her elbow. Despite broad-spectrum intravenous antibiotics, her right elbow swelling did not improve. A skin punch biopsy revealed epidermis with subacute spongiotic changes overlying oedematous and sclerotic dermis. The deep dermis and subcutis were diff usely necrotic and lined at the superfi cial edge by xanthogranulomatous infi ltrate consistent with lipomembranous fat necrosis (fi gure, A). No infectious organisms were initially identifi ed by stain or culture. Included in her extensive infectious work-up was a T-SPOT tuberculosis test, which returned a positive result. Subsequent induced sputum showed acid-fast bacilli that were identifi ed as Mycobacterium tuberculosis. The patient was started on a four-drug regimen for treatment (ethambutol 800 mg per day, isoniazid 300 mg per day, moxifl oxacin 400 mg per day, and pyrazinamide 1500 mg per day). After 3 weeks, right elbow skin biopsy acid-fast cultures became positive for M tuberculosis and a diagnosis of miliary tuberculosis was made. The patient’s elbow ultimately ulcerated and healed slowly within several months (fi gure, B), and the patient was seen to have the additional cutaneous manifestation of tuberculous gummas on her right forearm and in several other locations on her body. The patient completed 9 months of antimycobacterial therapy with clinical improvement and resolution of her cutaneous lesions. At 20-month follow-up after completion of therapy, the patient remains without evidence of active disease. Cutaneous involvement in miliary tuberculosis is rare, but is more common in immunocompromised patients. Rarely, this can result in a cellulitis-like appearance, as was seen at fi rst presentation in this patient. Unlike previous reports, the epidermal changes in this case were associated with lipomembranous fat necrosis. Interestingly, lipomembranous fat necrosis is regarded as a non-specifi c reaction pattern of adipose tissue to injury typically from an impaired blood supply. It can occur in a range of conditions, including vascular disorders, connective tissue diseases, and infl ammatory panniculitis. It has been reported in association with atypical mycobacteria, but an association with M tuberculosis has not been previously described. Although the pathogenic mechanisms that lead to lipo membranous fat necrosis remain unknown, miliary tuberculosis should be added to the list of related disorders.

Psychiatric misleading features of fatal pathologies: Legal implications

Summary Some cases of fatal pathologies may be presented on non-specific clinical symptoms. Unusual exam-findings can lead to some pitfalls and death occurred unfortunately. In this context, we report autopsy cases of miliary tuberculosis and acute pancreatitis misdiagnosed and we discuss the doctor's responsability. Case 1 N.M. is a 24-year-old lady. She was admitted with fever of forty days’ duration associated with headache and anorexia. Examination and radiological investigations did not show any abnormalities. The patient was symptomatically medicated and allowed to return home. After one week, she was discovered dead in her bed. The diagnosis of miliary tuberculosis was confirmed by histological examination after the necropsy. Case 2 A 22-year-girl with history of mental retardation, consulted twice in the emergency room, for inhabitual agitation. She was treated each time symptomatically without any improvement. Death occurred after two days. The forensic autopsy with the histological tests confirmed the diagnosis of necrotic-hemorrhagic pancreatitis. Conclusion Our two cases report highlights the necessity to be aware about atypical presentation of tuberculosis and acute pancreatitis that can lead to sudden death.

Diagnosis and management of miliary tuberculosis: current state and future perspectives

Tuberculosis (TB) remains one of the most important causes of death from an infectious disease, and it poses formidable challenges to global health at the public health, scientific, and political level. Miliary TB is a potentially fatal form of TB that results from massive lymphohematogenous dissemination of Mycobacterium tuberculosis bacilli. The epidemiology of miliary TB has been altered by the emergence of the human immunodeficiency virus (HIV) infection and widespread use of immunosuppressive drugs. Diagnosis of miliary TB is a challenge that can perplex even the most experienced clinicians. There are nonspecific clinical symptoms, and the chest radiographs do not always reveal classical miliary changes. Atypical presentations like cryptic miliary TB and acute respiratory distress syndrome often lead to delayed diagnosis. High-resolution computed tomography (HRCT) is relatively more sensitive and shows randomly distributed miliary nodules. In extrapulmonary locations, ultrasonography, CT, and magnetic resonance imaging are useful in discerning the extent of organ involvement by lesions of miliary TB. Recently, positron-emission tomographic CT has been investigated as a promising tool for evaluation of suspected TB. Fundus examination for choroid tubercles, histopathological examination of tissue biopsy specimens, and rapid culture methods for isolation of M. tuberculosis in sputum, body fluids, and other body tissues aid in confirming the diagnosis. Several novel diagnostic tests have recently become available for detecting active TB disease, screening for latent M. tuberculosis infection, and identifying drug-resistant strains of M. tuberculosis. However, progress toward a robust point-of-care test has been limited, and novel biomarker discovery remains challenging. A high index of clinical suspicion and early diagnosis and timely institution of antituberculosis treatment can be lifesaving. Response to first-line antituberculosis drugs is good, but drug-induced hepatotoxicity and drug–drug interactions in HIV/TB coinfected patients create significant problems during treatment. Data available from randomized controlled trials are insufficient to define the optimum regimen and duration of treatment in patients with drug-sensitive as well as drug-resistant miliary TB, including those with HIV/AIDS, and the role of adjunctive corticosteroid treatment has not been properly studied. Research is going on worldwide in an attempt to provide a more effective vaccine than bacille Calmette–Guérin. This review highlights the epidemiology and clinical manifestation of miliary TB, challenges, recent advances, needs, and opportunities related to TB diagnostics and treatment.

Tuberculous Cellulitis in a Patient with Chronic Kidney Disease and Polymyalgia Rheumatica

An 89-year-old man with advanced renal failure, polymyalgia rheumatica and a past history of tuberculosis was admitted with a high fever. Erythema and swelling appeared in the femoral region. Since the cellulitis failed to respond to antibiotic therapy, a skin biopsy was performed. The specimen showed the presence of epithelioid cell granuloma and panniculitis. Acid-fast organisms were found on Ziehl-Neelsen staining. A polymerase chain reaction test of tuberculosis was positive. Although a diagnosis of miliary tuberculosis was suggested, examinations of a bone marrow biopsy and fundoscopy revealed normal results. The patient's symptoms improved following treatment with isoniazid, rifampicin and ethambutol. This case represents an unusual presentation of tuberculous cellulitis in an immunocompromised patient.