Miliary tuberculosis leading to acute respiratory distress syndrome: Clinical experience in pediatric intensive care

Acute respiratory distress syndrome (ARDS) represents a rare complication of miliary tuberculosis (TB) in the adult setting, and it is even less common in the pediatric population. The presence of comorbidities and the possibility of a delayed diagnosis may further impair the clinical prognosis of critically ill patients with disseminated TB and acute respiratory failure. In this report, we present a case series of five pediatric patients with miliary TB and ARDS, where rescue and multimodal respiratory support strategies have been applied with a favorable outcome in more than half of them. The burden of miliary TB over time on a general pediatric intensive care unit—including two ARDS patients—is also illustrated.     

Drug susceptibility pattern of Mycobacterium tuberculosis in adult patients with miliary tuberculosis

Miliary tuberculosis (TB) is a fatal form of TB. Although drug resistance in TB patients has increased worldwide, there is limited information on drug resistance in miliary TB. This study from Pakistan evaluated drug susceptibility pattern among miliary TB patients of a high TB-burden country. All adult patients with miliary TB, admitted between 1994 and 2001, were identified using a computerized database. Culture-positive isolates were evaluated for drug susceptibility using middle brook 7H10 agar according to National Committee for Clinical Laboratories Standard criteria. Of 110 patients diagnosed with miliary TB, 32 (30%) were culture positive (yielding 35 culture isolates). The sources of positive cultures were sputum (37%), cerebrospinal fluid (18%), lymph nodes (12%), bone marrow (9%), bronchial wash (9%), urine (6%), lungs (6%) and liver (3%). Isoniazid resistance was found in three (9%) isolates. All the isolates were sensitive to rifampicin, ethambutol, pyrazinamide and streptomycin. Despite a worldwide increase in TB drug resistance, patients with miliary TB have infection with drug-sensitive mycobacterium. First-line anti-TB drugs should be used as initial therapy in miliary TB patients.     

Hospital-onset tuberculosis in compromised host.

A total of 21 patients developed active tuberculosis (TB) during hospitalization. Active TB was identified by bacteria-positive, biopsy or autopsy. Infection was confirmed to the lung, pleura, lymph node and miliary lesions and 7 patients had open tuberculosis. In half of the patients, chest X-ray films demonstrated unusual findings in adult tuberculosis: lower lung field pneumonia and miliary pattern. All the patients suffered from severe underlying diseases and an intensive therapy with steroid, immunosuppressive agents, antitumor drugs, radiation and operation was found as predisposing factors for TB occurrence. Nine patients recovered from current infection with anti-tuberculosis drugs; 14 patients died and TB directly caused death in 8 patients. These data strongly suggest that TB is one of the most important infections in compromised hosts. We emphasize that this infection presents a serious clinical problem in a general hospital today.     

Predictors of development and outcome in patients with acute respiratory distress syndrome due to tuberculosis.

OBJECTIVE: To study the predictors of development and determinants of outcome in patients with acute respiratory distress syndrome (ARDS) due to tuberculosis (TB). METHODS: Retrospective case-control study of demographic, clinical and laboratory data of hospitalised adult patients with active TB. RESULTS: Of 2733 TB patients treated during 1980-2003, 29 (1.06%; 1.21 patients/year; mean age 31.6 +/- 10.9 years; 16 males) developed ARDS (cases). Seven had pulmonary TB and 22 had miliary TB (MTB); 298 (mean age 32.0 +/- 14.2 years; 110 males) who did not develop ARDS constituted controls. Presence of MTB (OR 4.6, 95%CI 1.2-17.8; P = 0.02), duration of illness beyond 30 days at presentation (OR 177.9, 95%CI 39-811.7; P < 0.001), absolute lymphocyte count < 1625/ mm3 (OR 4.5, 95%CI 1.1-19.3; P = 0.04) and serum ALT > 100 IU (OR 15.7, 95%CI 3.0-81.1, P < 0.001) were independent predictors of ARDS development. Twelve cases died (41.4%). Patients with APACHE II score >18; those with APACHE II score <18 in the presence of hyponatraemia and PaO2/FIO2 ratio <108.5 were likely to die. CONCLUSIONS: In patients with TB, prolonged illness, MTB, absolute lymphocytopaenia and elevated ALT are independently associated with ARDS development. APACHE II score, serum sodium and PaO2/FIO2 ratio are determinants of outcome.     

Miliary tuberculosis: clinical manifestations, diagnosis and outcome in 38 adults

OBJECTIVE: The aim of the study was to determine the clinical, radiographic and laboratory characteristics, diagnostic methods, and prognostic variables in patients with miliary tuberculosis (TB). METHODOLOGY: The records of 38 patients (15 male, 23 female; mean age 41 years, range 16-76 years) with miliary TB from 1978 to 1998 were analyzed. Patients were evaluated also as to whether they presented with a fever of unknown origin (FUO). Criteria for the diagnosis of miliary TB were (i) miliary pattern on chest X-ray or (ii) biopsy or autopsy evidence of miliary organ involvement. Paraffin-embedded tissues with granulomata (n = 15) were re-evaluated for the presence of Mycobacterium tuberculosis DNA by polymerase chain reaction (PCR). RESULTS: Predisposing conditions were present in 24% of the patients. The findings were fever, weakness, night sweats, anorexia/weight loss (100% for each), hepatomegaly (37%), splenomegaly (32%), choroidal tubercles (13%), neck stiffness (11%), altered mental status (8%), anaemia (76%), leukopenia (26%), thrombocytopenia (16%), lymphopenia (76%), pancytopenia (8%) and hypertransaminasemia (55%). Eighteen patients (47%) met the criteria for a FUO. Miliary infiltrates were found on chest X-rays of 32 of 38 cases (84%). In six cases without miliary infiltrates, the diagnosis was made by laparotomy in four cases, and autopsy in two cases. Tuberculin skin test was positive in 32% of cases. Acid-fast bacilli were demonstrated in 37% (16/43), and cultures for M. tuberculosis were positive in 90% (9/10) of tested specimens (predominantly sputum and bronchial lavage). Granulomas were found in 85% (11/13) of lung, 100% (15/15) of liver, and 56% (9/16) of bone marrow tissue specimens. Acid-fast bacilli staining was negative in all (0/21), while PCR was positive in 47% (7/15) of specimens with granulomata. Mortality was 18%. Stepwise logistic regression identified male sex (P = 0.005), non-typical miliary pattern (P = 0.015), altered mental status (P = 0.002) and failure to treat for TB (P = 0.00001) as independent predictors of mortality. CONCLUSIONS: Miliary infiltrates on chest X-ray or FUO should raise the possibility of miliary TB. Therapy should be administered urgently to prevent an otherwise fatal outcome.     

Bone and joint tuberculosis concurrent with tuberculosis of other organs

OBJECTIVES: To study the characteristics of bone or joint tuberculosis (TB) accompanied by TB in other organs (especially the lung), and to study patients' and doctors' delay in detecting bone or joint TB. SUBJECTS AND METHODS: A retrospective study was conducted on 33 patients with bone or joint TB concurrent with TB of other organs, especially the lung, who were admitted to our hospital between 1981 and 2005. The patients were divided into the following three groups according to the organ of concurrent TB : (1) miliary TB group (N = 10), (2) pulmonary TB group (N = 19), and (3) other TB site group (N = 4). The relationship between bone/joint TB and TB of other organs was studied by comparing the three groups with respect to the time of appearance of musculo-skeletal symptoms or signs such as swelling and pain and that of symptoms or signs originating from other organs, such as cough, sputum, miliary pattern on chest radiograph and superficial lymph node swelling. RESULTS: The mean age (SD) of patients was 50.5 (18.9) yr, and the male to female ratio was 23 : 10. Among 33 patients, bone TB (including 18 spinal TB) was detected in 24 patients, joint TB in 14, and abscess in 3 (concurrent lesions in some patients). The mean intervals from onset of symptoms to consultation (patients' delay), from consultation to diagnosis (doctors' delay) and from symptom onset to diagnosis (total delay) were 5.5 (13.9), 3.4 (5.2) and 8.9 (13.9) months, respectively. (1) Bone/joint TB concurrent with miliary TB (N = 10) In 8 patients with mean age of 61.0 (17.4) yr, musculo-skeletal symptoms/signs preceded respiratory symptoms or appearance of miliary pattern on chest radiograph by 7.8 (7.2) (range; 1-24) months. The patients', doctors' and total delays were 0.4 (0.5), 7.3 (7.8), and 7.7 (7.6) months, respectively. In most cases, bone/joint TB was diagnosed after the onset of miliary pattern on chest radiograph. In one patient with simultaneous onset of musculo-skeletal and respiratory symptoms/signs (age 21 yr), the interval of total delay was 1 month, and in one patient with musculoskeletal symptoms which appeared six months later than respiratory symptoms (age 28 yr), the interval of total delay was 2 months. (2) Bone/joint TB concurrent with active pulmonary TB (N = 19). In this group, the mean age was 52.2 (17.1) yr, and males were predominant (M/F = 15/4). Active pulmonary TB was diagnosed by positive sputum culture in 13 patients, by positive sputum smear or PCR results in 4 patients, and by the clinical course in 2 patients. Ten patients (53%) had a previous TB history. Cavitary lesion was observed in 15 patients, and the upper lobes were predominantly involved on chest radiograph in 19 patients, indicating that the pulmonary TB was probably post-primary (reactivation) in all patients. In 9 patients with mean age of 49.7 (15.7) yr, musculo-skeletal symptoms/signs preceded respiratory symptoms by 14.1 (14.0) (range; 4-48) months. The patients', doctors' and total delays were 13.3 (17.8), 3.8 (6.6), and 17.1 (16.1) months, respectively. On the other hand, in 10 patients with mean age of 54.5 (18.7) yr, musculo-skeletal symptoms/signs and respiratory symptoms/signs appeared simultaneously, and the total delay was 2.7 (1.9) months. Twelve of 19 patients (63%) had complications such as diabetes mellitus, steroid use, and liver diseases. In cases with miliary or pulmonary tuberculosis, the total delay in diagnosis (Y) correlates positively with the time lag from onset of musculo-skeletal symptoms to respiratory symptoms/signs (X), and the regression line (Y = 0.94X + 2.3, r = 0.98, p < 0.001) was almost linear (Y = X), indicating that the diagnosis of bone/joint TB was made just after the diagnosis of miliary or pulmonary TB. (3) Bone/joint TB concurrent with TB of other sites (N = 4) In 2 female cases (21 and 28 yrs) with cervical lymph node TB, musculo-skeletal symptoms/signs and cervical lymph node swelling appeared simultaneously. In a 54-yr male patient, musculo-skeletal symptoms/signs appeared 5 years after appearance of testicular enlargement, and testicular TB was diagnosed by biopsy simultaneously. In a 33 year-old male patient, musculo-skeletal symptoms/signs appeared 7 months after the drainage of pleural and pericardial effusions (TB was not diagnosed initially), and then the diagnosis of bone/joint, pleural, and pericardial tuberculosis was made for the first time. CONCLUSIONS: In middle-aged or elderly patients with active bone/joint TB, miliary TB is sometimes caused by bacillemia originating from the infected bone/joint lesions. In cases with bone/joint TB and concurrent pulmonary TB, bone/joint TB and pulmonary TB are probably reactivated independently as a result of decreased systemic immunocompetence.     

住院肺结核患者合并急性呼吸窘迫综合征的多因素分析

目的　探讨导致住院肺结核患者合并急性呼吸窘迫综合征(ARDS)的危险因素。方法 收集2006年1月—2007年10月内科收治的肺结核患者1931例,合并ARDS的患者91例作为观察组(ARDS组),非ARDS患者采用随机方法 选取病例作为对照组(非ARDS组),比较2组各项观察指标,行单因素分析,对有显著性差异的指标进行多因素分析,以发现肺结核患者导致ARDS的多种相关因素,单因素分析采用χ²检验,多因素分析采用Logistic回归分析。结果 1931例住院肺结核患者中,91例合并ARDS,占住院肺结核患者的4.71%(91/1931)。经多因素分析,复治肺结核患者、合并慢性阻塞性肺疾病(COPD)、合并休克、血常规示白细胞增加、中性粒细胞百分比增加与住院肺结核患者发生ARDS相关,且均为危险因素。结论 住院肺结核患者中,复治肺结核患者、合并COPD、休克、全身性感染者更易发生ARDS。     

Miliary tuberculosis in Mali during the decade 2000-2009

In order to describe the epidemio-clinical and evolutionary aspects of miliary tuberculosis (TB) in Mali, a retrospective study of 10 years (1 January 2000 to December 31, 2009) was conducted in the service of pneumo-phtisiology at the university hospital of point G. It concerned all patients with radiological images compatible with miliary TB, signs of bacillary impregnation, bacillus or not, treated with antituberculosis drugs. Of 3630 TB patients all forms recorded during the study period, 183 miliary were recorded (5%) including 117 men and 66 women. Young adults between 29-45 years were more represented (52%). The average diagnostic delay was 3.7 months. The symptomatology was dominated by the fever (100%), cough (90.1%) and asthenia (86.3%), anorexia (81.9%). The radiological images types of micronodular opacities were the most frequent in 147 cases (80.3%) against 36 cases of (19.7%) macronodular types. Bacteriological examination of sputum was negative in 139 patients (76%) and positive in 44 patients (24%). There was a statistically significant relationship between the presence of an excavation in Chest radiography and smear positivity (P<0.001). The clinical improvement observed (55.7%) depended on the time of the diagnosis (P<0.001). The serology HIV was positive at 29 patients on 124 tested. Also, in areas with high prevalence TB/HIV, any miliary fever in the absence of other obvious etiologies should undertake without delay TB proper treatment.     

HIV seroprevalence in patients with tuberculosis]

The number of patients co-infected with human immunodeficiency virus (HIV) and tuberculosis (TB) in our hospital is increasing year after year. Although most patients were HIV tested because of miliary tuberculosis or extra-pulmonary tuberculosis, some patients were found HIV seropositive by chance. In order to determine the incidence of HIV seropositivity among TB patients, HIV testing was carried out in TB patients for two years from January 1998 with the consent of patients. TB patients who received anti-HIV antibody examination were 164 in 1998, and 149 in 1999 and among them HIV seropositive TB patients were 4 in 1998 and 6 in 1999. The incidence of HIV seropositivity was 3.2% in all TB patients, 28.6% in miliary TB patients, and 1.0% in typical TB patients. The number of patients co-infected with HIV and TB in Tokyo was estimated by using these HIV seropositivity, it was 23 cases/year among miliary TB patients and 16 cases/year among typical TB patients. As there were many HIV-infected persons and many TB patients in Tokyo, it was thought that HIV testing in TB patients was important for the early detection of HIV infection and the early initiation of HIV treatment.     

Clinical aspects of miliary tuberculosis in Saudi adults.

OBJECTIVE: To review all cases of miliary tuberculosis (MT) over a period of 7 years in a Saudi Arabian population, to determine the clinical and laboratory characteristics and diagnostic methods, and to compare our data with others reported in the literature. DESIGN: A retrospective case review. RESULTS: Of 780 cases of active tuberculosis seen over period of 7 years, 47 (6%) had MT. The majority of the patients were aged over 60 years (68%). The most common symptoms were fever and weight loss. Risk factors were present in 70% of cases, mainly diabetes mellitus, history of prior tuberculosis, chronic liver and renal disease, immunosuppressive drug therapy and malignancy. Miliary pattern on chest radiography was seen in 89%. The most common laboratory abnormalities were anemia (66%), lymphopenia (89%), low albumin (87%), and high alkaline phosphatase (80%). Fiberoptic bronchoscopy was diagnostic in 7/10 (70%), bone marrow examination in 8/11 (73%), and liver biopsy in 14/16 (88%). High alkaline phosphatase and lymphopenia were associated with high yield of liver biopsies and bone marrow examination: 13/14 (93%) and 7/8 (88%), respectively. Death occurred in 10/47 (21%); all of these had radiological evidence of miliary pattern, and 80% had comorbid conditions. CONCLUSION: These data confirm and extend the results of other studies and suggest that MT is a disease of the elderly and immunocompromised, and is associated with high mortality. A high index of suspicion is required for diagnosis.     

Clinical characteristics of 110 miliary tuberculosis patients from a low HIV prevalence country.

SETTING: A university teaching hospital in Karachi, Pakistan. OBJECTIVE: To define the clinical characteristics and outcome of miliary tuberculosis (TB) patients from a low human immunodeficiency virus (HIV) prevalence country. DESIGN: Review of adult miliary TB patients admitted between 1994 and 2001. Clinical characteristics of those dying from miliary TB were compared with those of the survivors. RESULTS: Most of the 110 cases reviewed were middle aged or elderly, with a female preponderance. An underlying medical condition was present in 47%. Presenting symptoms were of several weeks' duration, and mostly constitutional (fever and weight loss). Common laboratory findings included anaemia (62%), lymphopaenia (71%), hyponatraemia (74%), elevated serum alkaline phosphatase (57%) and hypoalbuminaemia (92%). Typical miliary pattern was observed in 77% of radiographs. Sputum smear and culture were positive in respectively 36% and 52% of those tested. Biopsy was performed in selected patients. Mean hospital stay was 8.8 days, and mortality was 30%. Those who died were significantly older than survivors and had a more fulminant course. Presence of altered mental status, lung crackles, leucocytosis, thrombocytopaenia and the need for ventilation were associated with increased mortality. CONCLUSION: Miliary TB carries a high mortality. It should be considered in patients who present with prolonged systemic symptoms. A positive TB culture or biopsy is needed to establish a diagnosis.     

Evaluation of accuracy of clinical diagnosis of TB by annual autopsy report

PURPOSE: To investigate the accuracy of clinical diagnosis of TB in Japan in recent years and to compare them with previous studies. METHOD: Data (sex, age, clinical diagnosis, pathological diagnosis as cause of death) on deceased cases clinically or pathologically diagnosed ante mortem as having tuberculosis was collected from annual reports of the pathological autopsy cases in 1984, 1989, 1994, and 1999-2004. Information on TB death from population statistics in those 9 years also was collected and compared with data of autopsied cases. RESULT: Autopsy rate in these years was stably around 10 %. Comparison of gender ratio and mean age between the two surveys showed similar numbers. During 1999-2004, 1725 death cases were diagnosed as TB clinically or pathologically. Number of pathologically proven pulmonary TB cases was 429 and that of miliary TB was 283. 55.7% of pulmonary tuberculosis and only 21.9% of miliary tuberculosis were correctly diagnosed before death. Out of 156 cases clinically diagnosed as non-TB diseases but proven as TB pathologically, 30.8% of clinical diagnosis was pneumonia and/or bronchitis, followed by diagnoses of interstitial pneumonia, respiratory failure, pneumoconiosis and lung cancer. However, the main clinical diagnoses of 175 miss-diagnosed miliary TB cases were diseases other than pulmonary diseases such as renal failure, malignant diseases and sepsis. CONCLUSION: In order to reduce undiagnosed pulmonary TB cases and to prevent nosocomial TB infection, differential diagnosis among pneumonia and/or bronchitis cases should be done. In case of miliary TB, not only pneumonia but also diseases other than pulmonary diseases such as renal failure, malignant diseases and sepsis should be included in the list differential diagnosis.     

Persistent radiological changes following miliary tuberculosis in miners exposed to silica dust.

SETTING: Silicosis leads to increased susceptibility to tuberculosis, but it has also been suggested that tuberculosis may interact with intra-pulmonary silica to exacerbate fibrotic lung disease. OBJECTIVES: To investigate the possibility that silicosis developed due to or was exacerbated by tuberculosis. METHODS: In a case series of 15 miners presenting with culture-positive miliary tuberculosis, serial radiographs taken premorbidly, at presentation, and after 2 and 6 months of standard anti-tuberculosis treatment were graded for nodularity using the International Labour Organization system. RESULTS: Increased nodule profusion (compared to premorbid film) remained in 13 (87%) and eight (53%) patients after 2 and 6 months of treatment, respectively, despite clinical improvement in all and documented bacteriological cure in eight (53%). These phenomena, observed irrespective of human immunodeficiency virus (HIV) status, were most pronounced in men with minor premorbid changes. Abnormal pulmonary collagenisation related to silica particles was apparent at post-mortem in two men who died of HIV-associated cryptococcosis after completing TB treatment. CONCLUSIONS: Previous silica exposure appears to result in delayed and potentially incomplete radiological resolution of miliary TB. We postulate that the immune response in tubercles may evoke a 'bystander' fibrotic response, as cytokines play a central role in the pathogenesis of both TB and silicosis.     

Clinical characteristics of <Emphasis Type="Italic">Mycobacterium tuberculosis</Emphasis> infection among rheumatoid arthritis patients

To evaluate the clinical characteristics of Mycobacterium tuberculosis infection in rheumatoid arthritis (RA) patients, we examined the clinical manifestations and radiography/computed tomography (CT) findings in RA patients with tuberculosis (RA+/TB+). A total of 1121 tuberculosis patients were admitted to our hospital from 1995 to 2003, with the RA patients among them comprising 1.8% (20 cases; 9 men and 11 women). This is approximately three times as high as the prevalence of RA in the entire population in Japan. In addition, the RA+/TB+ patients were older and had a longer history of RA than the 140 outpatients in our RA clinic who did not have tuberculosis (RA+/TB–). Half of the RA+/TB+ patients had no symptoms (e.g., cough, sputum, pyrexia), and their tuber-culosis was detected accidentally by radiography/CT. The positive rates of the bacilli in the smear and culture of the sputum from the RA+/TB+ patients were lower than those from 143 patients randomly selected from among 1091 tuberculosis patients without any collagen disease including RA (RA–/TB+). The RA+/TB+ patients had a higher incidence of extrapulmonary tuberculosis (30%), including four cases (20%) of miliary tuberculosis, an incidence seven times higher than among the general population of tuberculosis patients. Among 14 cases of pulmonary tuberculosis patients with RA, bilateral lesions and noncavitary lesions were found in 71.4% and 64.3%, respectively, which tended to be a higher incidence than in the RA–/TB+ patients. The mortality rate and sputum conversion time of the RA+/TB+ patients were no different from those of the RA–/TB+ patients. The prevalence of tuberculosis in RA patients is expected to increase after introduction of anticytokine therapy in Japan, and careful observation should be done to avoid this complication in RA patients.     

Disseminated tuberculosis in the acquired immunodeficiency syndrome era

To assess the influence of human immunodeficiency virus type 1 (HIV)-induced immunodeficiency on the clinical, radiographic, and pathologic features of disseminated tuberculosis (TB), we studied 79 patients presenting in 1984 through 1987 with miliary or focal disseminated disease due to Mycobacterium tuberculosis, as well as 4 additional non-HIV patients diagnosed after 1987. Clinically defined acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (ARC) was present in 51 (Group 1). A total of 20 had TB unrelated to HIV disease (Group 2). The remaining 12 were excluded because the role of HIV could not be determined. Clinical features were similar between groups aside from younger age; lower hemoglobin, total leukocyte, lymphocyte, and platelet counts; and more frequent tuberculin anergy (90 versus 40%) in AIDS/ARC patients (p less than or equal to 0.03). Chest radiographs showed a miliary pattern in about half of each group. Pleural effusion occurred only in AIDS/ARC patients (24%, p = 0.02), but intrathoracic lymphadenopathy was present in about a third of each group. Tissue biopsies (n = 70) usually revealed necrotizing granulomatous inflammation in each group, with a tendency to greater necrosis and more numerous acid-fast bacilli in Group 1. Granulomas were usually poorly formed in AIDS/ARC patients (59 versus 18%, p = 0.01). Autopsy of 9 AIDS/ARC patients with overwhelming miliary TB revealed a "nonreactive" histologic pattern with poorly organized or absent granulomas, extensive necrosis, and numerous bacilli. HIV-related disseminated TB causes a major constitutional illness with a high short-term mortality (25%).(ABSTRACT TRUNCATED AT 250 WORDS)     

肺结核并发各种类型肺外结核患者的分布及其耐药情况分析

目的 探讨肺结核并发各种类型肺外结核患者的分布及其耐药情况。方法 选取2013年1月至2015年12月在首都医科大学附属北京胸科医院住院治疗的347例肺结核并发肺外结核患者(男199例,女148例)为研究对象,回顾性分析患者的年龄、性别、肺外结核并发感染部位等临床特征,同时对痰菌培养阳性的结核分枝杆菌临床分离株进行药物敏感性试验。比较分析并发不同类型肺外结核患者的耐药情况。结果 347例肺结核并发肺外结核患者中,中位年龄33(24~52)岁,其中高发年龄为20~39岁,占41.8%(145/347)。常见并发肺外结核的类型依次为:骨关节结核112例(32.3%,112/347),淋巴结结核96例(27.7%,96/347),结核性脑膜炎82例(23.6%,82/347),结核性腹膜炎23例(6.6%,23/347),结核性心包炎9例(2.6%,9/347),肠结核8例(2.3%,8/347),泌尿系结核和结核性多浆膜炎各5例(各占1.4%,5/347),肾结核2例(0.6%,2/347),脾结核、女性盆腔结核、肝结核、附睾结核和鼻结核各1例(各占0.3%,1/347)。并发骨关节结核、淋巴结结核、结核性脑膜炎、结核性腹膜炎和其他类型肺外结核患者的中位年龄分别为:47(26~60)岁、26(20~42)岁、34(25~50)岁、26(20~46)岁和47(31~66)岁;上述各组中位年龄之间比较,差异有统计学意义(χ ²=36.25,P=0.000)。347例患者中有189例患者进行了痰培养,对其中70例细菌培养阳性的临床分离株进行的药敏试验结果显示,肺结核并发肺外结核的总体耐药率为44.3%(31/70),单耐药率、多耐药率和耐多药率分别为11.4%(8/70)、2.9%(2/70)和30.0%(21/70)。 结论 肺结核并发肺外结核的累及部位广泛,其中最为常见的累及部位为骨关节、淋巴结和脑膜。肺结核并发肺外结核的总体耐药率高。     

HRCT shows variations in appearance in disseminated tuberculosis in adults.

OBJECTIVE: To examine patterns of high resolution computed tomography (HRCT) of lungs of adults with disseminated tuberculosis (TB). DESIGN: Disseminated TB was defined as radiological involvement of all lung lobes. RESULTS: The case series illustrated wide variation in HRCT of disseminated TB. Patterns identified on HRCT included (1) miliary TB (haematogenous dissemination), (2) miliary TB with exudative reaction, (3) bronchogenic spread, (4) miliary TB mixed with bronchogenic spread, and (5) bronchogenic spread with multiple cavity formation. CONCLUSION: The HRCT patterns described allow classification of disseminated TB according to the mechanism of spread (haematogenous and/or bronchogenic) and the degree of local lung involvement (reaction or cavitation).     

Tuberculous meningitis and miliary tuberculosis in young children

OBJECTIVES: To document the clinical and diagnostic features of tuberculous meningitis (TBM) in young children with and without concomitant miliary tuberculosis (TB). METHODS: A retrospective comparative study. RESULTS: Of 104 children with TBM, 32 (31%), median age 17.0 months, had a miliary appearance on chest radiograph; 72 (69%), median age 30.5 months, had TBM only (P = 0.04). Mediastinal adenopathy was noted in 27 (84%) of the children with miliary TB and 33 (46%) of those with TBM only (P = 0.0005). The mean cerebrospinal fluid (CSF) lymphocyte and polymorphonuclear counts of all children (no significant differences between groups) were 137 x 10(6)/l and 38 x 10(6)/l and the mean protein and glucose concentrations were 1.45 g/l and 0.72 mmol/l, respectively. Polymorphonuclear leukocytes were predominant in the CSF of 17% of children, in 16% the CSF glucose was > 2.2 mmol/l and in 26% the CSF protein was < 0.8 g/l. On Mantoux testing 37 (65%) of 57 children with TBM only and 12 (48%) of 25 children with TBM and miliary TB had an induration of > or = 10 mm (P = 0.23). Ten children (10%) died, five (7%) who had TBM only and five (16%) who had TBM and miliary TB. CONCLUSION: Children with TBM and miliary TB were younger and more likely to have mediastinal adenopathy on chest radiography than those with TBM only. Diagnostic features and investigations in both groups may be misleading at times.     

Three cases of tuberculosis complicating acute respiratory distress syndrome

In this report, we describe three patients with pulmonary tuberculosis with acute respiratory failure with an extensive tuberculous consolidation in bilateral lung fields. Disseminated intravascular coagulation (DIC) was present in one patient and miliary tuberculosis in two patients. They all developed acute respiratory distress syndrome (ARDS), nessecitating management by mechanical ventilation with a combination therapy of antituberculous agents and methylprednisolone (m-PSL) pulse therapy. Only one patient survived in whom the PaO2/FiO2 ratio recovered rapidly after the initiation of therapy. Two patients whose systemic condition upon admission was critically ill eventually died of hepatic failure and bacterial pneumonia, even though ARDS and pulmonary tuberculosis were successfully treated. Prognosis of pulmonary tuberculosis complicating ARDS and DIC is poor, and these patients need systemic intensive treatment, in which m-PSL therapy may be beneficial.     

The adult respiratory distress syndrome associated with miliary tuberculosis

Two cases of pathologically confirmed miliary pulmonary tuberculosis complicated with ARDS were presented. Both had systemic lupus erythematous and used maintenance dose of corticosteroid. Case one developed respiratory distress and severe hypoxemia one day postpartum and chest radiograph revealed nodular and miliary infiltrations and pleural effusion. The patient was intubated and placed on a volume-cycled ventilator. A FIO2 of 70% and a PEEP of 0.98 kPa were required to maintain the oxygen tension at 6.95 kPa. The effective compliance of the lung decreased progressively and the patient died 5 days later. Autopsy revealed disseminated tuberculosis extensively involving the lungs, the liver and kidney. The alveoli were filled with edematous fluid with formation of hyaline membranes and micro-atelectasis. Case two developed respiratory distress and pulmonary edema at the third month of pregnancy. Cardiopulmonary arrest occurred when trying to intubate the patient. Postmortem needle puncture of the lungs and liver revealed charges comparable with tuberculosis and ARDS. In considering the relatively high incidence of pulmonary tuberculosis in China, the percentage of miliary tuberculosis as a potential cause of ARDS might not be very low. It is important to maintain a high index of suspicion for this treatable precipitating disorder and initial appropriate therapy early enough in patients with ARDS.