The complication with tuberculosis of the central nervous system in patients with miliary tuberculosis

The complication with tuberculosis of the central nervous system (CNS) were studied in 16 patients with miliary tuberculosis who were admitted to our hospital during a period of two years from April, 1997 to March, 1999, and were examined by head MRI. Twelve cases (75%) were diagnosed as having tuberculosis of CNS. Six cases had tuberculosis of CNS which was found during the screening of miliary tuberculosis cases, and all had only cerebral tuberculoma. Meningeal irritative symptoms led to the discovery of tuberculosis of CNS in the remaining six cases, in which cerebral tuberculoma was complicated with tuberculous meningitis. Of these cases of meningitis, three cases showing disturbance of consciousness died, but no cases of death was found in cases by the screening. The length of time from the onset of symptoms to the diagnosis of tuberculosis was long in many of the cases complicated with tuberculosis of CNS compared with the cases without such a complication. In the cases of miliary tuberculosis, the rate of complication with tuberculosis of CNS is high, and the possibility of patients developing serious symptoms suddenly even when they were asymptomatic at the time of diagnosis and the paradoxical expansion that becomes intensified after initiation of treatment have been reported. Therefore, it is necessary to make a close checkup of CNS when the diagnosis of miliary tuberculosis has been made.     

妊娠合并急性粟粒型肺结核病30例

目的 探讨妊娠合并急性粟粒型肺结核病的临床特征。方法 回顾分析30例妊娠合并急性粟粒型肺结核病临床有关资料。结果 30例占同期同龄住院女性的40％，好发于妊娠早期、分娩及流产后；易合并肺外结核，尤其是结核性脑膜炎(占26．7％)；发病至诊断中位时间45日；早产率35．7％，围生儿死亡率21．4％。结论 妊娠及分娩是已婚妇女易患急性粟粒型肺结核病的重要诱因，且易误诊及延误诊断，应引起重视。妊娠期确诊后应及时治疗，推迟至产后治疗是不正确的。     

A case of apyretic miliary tuberculosis which was discovered accidentally

A 78 year-old female was referred to our hospital, because diffuse miliary shadows in bilateral lung fields were discovered during upper G.I. series. She did not complain of fever or display any chest symptoms. Her laboratory data on admission revealed mild hypoxemia and high serum CA 19-9. The transbronchial lung biopsy specimen proved epithelioid cell granulomas. M. tuberculosis was observed on culture from the sputa, urine and bronchoalveolar lavage fluid. She was diagnosed to have miliary tuberculosis, and antituberculous drugs were administered. After the antituberculous therapy, the diffuse miliary shadows on the chest X-ray diminished gradually, and the laboratory data improved. No elevation in the body temperature was seen during the entire clinical course. Though it is known that miliary tuberculosis in elderly patients is often atypical and has mild symptoms, miliary tuberculosis without fever is very rare.     

A case of miliary tuberculosis showing acute respiratory failure during pregnancy]

A 36-year-old Philippine woman had had fever and general fatigue from September, 2006 (11th week of pregnancy). She was admitted with high fever, general fatigue and dyspnea on October 16, 2006 (13th week of pregnancy). A chest radiograph on admission showed bilateral miliary shadows and ground glass shadows. She already had severe hypoxia on admission. As acid-fast bacilli were positive in urine (Gaffky 8) and sputum (Gaffky 1), we diagnosed as miliary tuberculosis and pulmonary tuberculosis complicated with acute respiratory distress syndrome (ARDS). We treated her with antituberculosis chemotherapy, corticosteroid, sivelestat sodium hydrate, direct hemoperfusion using a polymyxin B immobilized column, and mechanical ventilation, but she died due to respiratory failure. We emphasize that in this case pregnancy has the risk of to causing disease progression of miliary tuberculosis and we should treat immediately and intensively for miliary tuberculosis complicated with ARDS.     

A case of tuberculous aneurysm of subclavian artery occurred in the course of treatment for miliary tuberculosis

This case is a 56-year old woman. Steroids were being administered perorally after a thymectomy for myasthenia gravis. A fever of 38-39 degrees Celsius appeared during night, an abnormal shadow showed up on a chest X-ray and the patient was hospitalized. Gaffky No. 2 acid-fast bacilli were detected in the patient's sputum and the chest CT showed diffuse granular-like shadow, the patient was diagnosed as miliary tuberculosis and treatment with combined use of INH, RFP, EB, and PZA was started. Subsequently, fever started to subside and the miliary shadow on chest X-ray improved, however, six weeks after the start of treatment, hoarseness and dysphagia appeared. From the cervical CT and cervical angiography findings, the diagnosis of right subclavian artery impending ruptured aneurysm was made. Because the patient's sputum was acid-fast bacilli positive and because the patient had undergone thymectomy, it was decided that it would be difficult to treat her by a thoracotomy again. Therefore, a right subclavian artery stent insertion, right subclavian artery-right common carotid artery bypass creation operation was carried out with the objective of blocking the flow of blood to the aneurysm. The hoarseness and dysphagia improved post-operatively and the patient's progress is being monitored. Tuberculous aneurysms are a rare affection and they are mostly discovered when the autopsy is done, however, this case was diagnosed due to the manifestation of subjective symptoms. While this case was not diagnosed histopathologically, it is envisaged from the clinical progress that this was a tuberculous subclavian aneurysm complicated during the treatment for miliary tuberculosis.     

Unusual cutaneous manifestations of miliary tuberculosis.

Cutaneous manifestations of miliary tuberculosis are extremely rare. We describe a 62-year-old woman with leukopenia who developed infiltrated dermal-hypodermal and ulcerative cutaneous lesions during the course of miliary tuberculosis. Miliary tuberculosis was diagnosed when Mycobacterium tuberculosis bacilli were isolated by cultures of the bronchoalveolar lavage fluid and blood and when acid-fast bacilli were detected on histopathologic examination of hepatic, pulmonary, and cutaneous biopsy specimens. With the increasing incidence of immunocompromised patients, unusual presentations of tuberculosis may be observed more often. Acute miliary tuberculosis of the skin is an exceptional manifestation that is due to acute hematogenous dissemination of M. tuberculosis to the skin. We describe a patient who had unusual cutaneous manifestations of miliary tuberculosis.     

Miliary tuberculosis and necrotizing tuberculous fasciitis – An unusual coexistence in a rheumatoid arthritis patient

We report a case of a 65‐year‐old Korean female patient with rheumatoid arthritis, who presented with extensive necrotizing fasciitis of the gluteus muscles, as an unusual initial manifestation of miliary tuberculosis. The patient had been previously treated with conventional disease‐modifying antirheumatic drugs and low‐dose steroids for 7 years. However, she recently developed fever, warmth and painful swelling in her right buttock. Magnetic resonance imaging indicated necrotizing fasciitis of the gluteus muscles and a fasciectomy specimen revealed a Mycobacterium tuberculosis infection. Two weeks after a fasciectomy, miliary tuberculosis of the lung was diagnosed by high resolution chest computed tomography. Soft tissue infection due to M. tuberculosis should be included as a differential diagnosis in the immunocompromised host. Clinicians should be alert to the possibility of miliary tuberculosis even in the absence of respiratory symptoms and normal chest radiograph.     

Clinical presentation of tuberculosis and the degree of immunodeficiency in patients with HIV infection.

A retrospective study of 80 HIV patients diagnosed with tuberculosis was carried out in order to evaluate the clinical presentation of tuberculosis (CPT) in relation to the degree of HIV-induced immunodeficiency, as determined by the CD4 lymphocyte count and reactivity to the tuberculin and delayed-type hypersensitivity reaction (DHR) skin tests by applying 2TU of RT-23 tuberculin, and the Muiltest IMC Merieux, respectively. CPT classification was undertaken on the basis of the location of the disease: pulmonary tuberculosis (PT), distinguishing between typical pulmonary (TP) and atypical (AP) according to the radiological pattern; extrapulmonary (ET); mixed tuberculosis (MT) pulmonary and extrapulmonary; and miliary tuberculosis. The CD4 lymphocyte count was 264.6 +/- 226.8, the TP had the highest number (505), MT had 132 (p < 0.001) and the miliary tuberculosis had 148 (p < 0.001), the lowest. The tuberculin skin test was positive in 35%, of which 11% were MT (p < 0.05). In the delayed-type hypersensitivity reaction, 67% were non-normoergic, of which 95% and 100% were MT and miliary tuberculosis, respectively (p < 0.05). There was a good overlap between CD4 depletion and skin tests. TP exhibited moderate immunodeficiency, AP severe immunodeficiency, and mixed and miliary TB extremely high immunodeficiency.     

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.     

A case of miliary tuberculosis complicating acute Q fever]

A 73-year-old man was admitted with fever and abnormal liver function test. After admission, his fever persisted in spite of administrating a variety of antibiotics. He was diagnosed as acute Q fever on the basis of a high titer of IgM antibodies against phase II Coxiella burneti. His fever resolved after starting minocycline, but biliary enzymes continued to be elevated. Transbronchial lung biopsy and percutaneous liver biopsy revealed caseating granulomas and Mycobacterium tuberculosis was detected by culture. Miliary tuberculosis was diagnosed and his biliary enzymes declined after starting therapy with antituberculous drugs. This report of miliary tuberculosis complicating acute Q fever is a valuable and unprecedented case.     

Clinicopathological study of miliary tuberculosis in patients with hematologic disease

Seven cases of miliary tuberculosis in patients with hematologic disease were analyzed clinicopathologically. Mean age of the patients was 65 years, and the hematologic diseases were CML, AML, ALL, MDS and malignant lymphoma. Diabetes mellitus was present as a complication in three patients. Miliary tuberculosis was found in 5 cases during the first admission to our hospital owing to hematologic problems. In 4 of 6 cases, fever had started more than two months before admission, consequently, the tuberculosis probably began about that time. After admission, chemotherapy was administered in 5 cases, and steroid in 6 cases for hematologic disease. The mean total quantity of steroid administered was 2,134 mg of prednisolone and average treatment duration was 69 days. The chest roentgenographic shadow was so atypical that miliary tuberculosis was suspected in only one case. The initial chest roentgenogram showed hilar and mediastinal lymph node swelling as well as the shadow of pulmonary tuberculosis in two cases. It was thought that the hilar and mediastinal lymph node swelling could be explained by primary complex, although the patients were of advanced age, or by "secondary complex" reported by Terplan, K in 1940. The diagnosis of tuberculosis was made in two patients before their death by smear of aspirated fluid of cervical lymph node and by bone marrow cell block in one patients, and by pathological examination of mediastinal lymph node biopsy in the other patients. Tubercles were found from bone marrow cell block in 2 out of 5 patients and from bone marrow biopsy in 1 out of 3 patients, but the positive results were reported in 2 patients following death. Smears of sputum, gastric juice, urine, spinal fluid and pleural effusion were negative in all cases. One patient diagnosed as miliary tuberculosis also had pneumocystis carinii pneumonia. This case was treated with antituberculosis drugs for 20 days without improvement. Another patient diagnosed as miliary tuberculosis improved under treatment with antituberculosis drugs, but died of cytomegalovirus pneumonia. Autopsy in 5 cases revealed non-reactive miliary tuberculosis, and pulmonary hemorrhage probably due to DIC was present as a complication in two cases. In these cases, severe immunosuppression, which is a major precipitating factor of miliary tuberculosis, is thought to be induced by hematologic disease itself, chemotherapy, steroid or other underlying disease such as diabetes mellitus. Miliary tuberculosis in such compromised host is cryptic and progresses rapidly. Consequently, early diagnosis is very important. Retrospectively, the unexplained pyrexia was most important to suspect tuberculosis.(ABSTRACT TRUNCATED AT 400 WORDS)     

Active tuberculosis undiagnosed until autopsy

In this report 21 patients in whom tuberculosis was the primary cause of death, but which was not diagnosed until necropsy, are reviewed. Of the 21 deaths, 11 were due to pulmonary tuberculosis and 10 to miliary tuberculosis. Proper evaluation of the following factors might have led to the correct diagnosis in many of the patients: A family history of tuberculosis, prior pleurisy, a gastrectomy, diabetes mellitus or end-stage renal failure; all can be associated with an increased incidence of tuberculosis. A negative tuberculin skin reaction does not exclude the presence of active tuberculosis. In the search for Mycobacterium tuberculosis, the examination of just one or two sputum specimens is not an adequate bacteriologic investigation. A positive gastric smear can have diagnostic importance. Ascitic fluid findings can be characteristic of tuberculous peritonitis. A negative bone marrow aspirate for acid-fast bacilli does not exclude miliary tuberculosis. Significant anemia, high fever and leukopenia increases the possibility of tuberculosis. The persistence and/or progression of lung infiltration, irrespective of supposedly specific antibiotic therapy, strongly suggests tuberculosis. Miliary tuberculosis can present as an adult respiratory distress syndrome. All but one patient in this series had fever. The failure to diminish the pyrexia believed due to specific lung infections with presumably effective antibiotics, and the inability of therapy to control other conditions thought to cause the fever indicate the presence of tuberculosis. Tuberculosis, especially miliary disease, should be considered as a possible etiology of fever of unknown origin.If the diagnosis of tuberculosis is highly suggestive, even without bacteriologic confirmation, a therapeutic trial of antituberculosis drugs should be given.     

Transbronchial Cryobiopsy for Miliary Tuberculosis Mimicking Hypersensitivity Pneumonitis

Miliary tuberculosis is a potentially lethal type of tuberculosis that results from the hematogenous dissemination of Mycobacterium tuberculosis bacilli. We herein describe the case of a 34-year-old man that presented with a one-month history of cough and fever, while his sputum smear results were negative. Chest computed tomography revealed bilateral centrilobular ground-glass opacification (GGO), suggestive of hypersensitivity pneumonitis; thus, bronchoscopy was performed. Cryobiopsy specimens revealed necrotic granulomas. A re-examination of sputum after bronchoscopy identified Mycobacterium tuberculosis, and miliary tuberculosis was diagnosed. A cryobiopsy might be useful for diagnosing miliary tuberculosis pathologically, particularly when miliary nodules may be masked by GGO.     

Hepatic tuberculosis in absence of disseminated abdominal tuberculosis

Liver involvement in tuberculosis in absence of miliary tuberculosis is rare. This study was performed to analyse the spectrum and response to treatment of hepatic tuberculosis in the absence of miliary abdominal tuberculosis. Retrospective analysis of seven cases of hepatic tuberculosis without miliary abdominal tuberculosis who presented at the single tertiary referral center were analyzed. All patients presented with fever and hepatomegaly. Five of them had pain in upper abdomen and vomiting. HIV serology was positive in one patient. All patients had normocytic normochromic anaemia, raised erythrocyte sedimentation rate (Mean 65). Mild elevation of liver enzymes and low albumin (Mean 2.4 gm%) with reversal of albumin globulin ratio (Mean 0.6) were seen in all. Two had jaundice. Prothrombin time was normal in all and lactate dehydrogenase values were elevated in all (Mean 794 IU/L). On ultrasonography, 2 had multiple hypodense lesion, 1 had coarse echotexture of liver, 1 had hyperechoic pattern and 3 had just hepatomegaly. Complete resolution of liver lesions on treatment with 4-drug anti-tuberculosis drug chemotherapy was seen. In conclusion, liver tuberculosis has protean manifestations with nonspecific alteration of liver function tests and is best diagnosed on liver biopsy. Overall response to therapy is satisfactory.     

A case of miliary tuberculosis complicated by acute respiratory failure after bronchofiberscopy]

A 79-year-old man presented with persistent nonproductive cough and high fever. The chest radiograph showed bilateral miliary shadows. We performed bronchoalveolar lavage and transbronchial lung biopsy to assist diagnosis. Severe dyspnea developed after the bronchofiberscopy, when the chest radiograph revealed bilateral ground-glass shadows and the oxygen saturation in the room air fell to 60%. It was suspected that the patient had acute respiratory distress syndrome, so that methylprednisolone was given intravenously at a dose of 250 mg daily for 3 days, which resulted in a reduction in ground glass shadows and an improvement in oxygen saturation. We diagnosed miliary tuberculosis because the transbronchial lung biopsy specimen showed caseous granuloma and the PCR test for Mycobacterium tuberculosis in the bronchoalveolar lavage fluid was positive. The patient was cured with antituberculosis chemotherapy.     

A rare presentation of tuberculosis. Miliary tuberculosis in a immunocompetent patient

Currently, miliary TB has a higher incidence among the elderly and immunodepressed patients, and exceptionally in young adults. A case of miliary tuberculosis was diagnosed in a young immunocompetent patient without using invasive techniques. The clinical and diagnostic implications will be discussed.     

Tuberculous subcutaneous abscesses developing during miliary tuberculosis therapy

Although rare, paradoxical subcutaneous abscesses may develop during appropriate treatment of miliary tuberculosis. While the pathogenesis of this phenomenon is not clear, some theories have been postulated. A case of a 37-y-old woman diagnosed as having miliary tuberculosis who developed subcutaneous abscesses within the 5 months of antituberculous treatment is described and all 6 similar cases published in English from 1954 to 1999 are discussed.     

Atypical cutaneous findings in a patient with systemic lupus erythematosus

A previously diagnosed systemic lupus erythematosus patient presented with arthralgia, skin rash and muscular weakness. When treated with high-dose corticosteroids and methotrexate she improved, except for a persistent lesion in the hand which evolved into a profound ulcer, along with tender subcutaneous nodules in the calf. A skin biopsy disclosed necrotizing vasculitis with giant cell granuloma revealing acid fast positive bacteria on ziels nilsen staining. A chest X-ray disclosed miliary tuberculosis (TB). The patient was diagnosed as miliary TB with prominent cutaneous involvement and treated with four anti-tuberculous drugs with slow resolution of her systemic, pulmonary and skin signs.     

Cutaneous miliary tuberculosis in a renal transplant patient: a case report and literature review

The incidence of tuberculosis in renal transplant recipients is higher than in the general population. However, the incidence of cutaneous miliary tuberculosis in these patients is very rare. We report a 56-year-old renal transplant Thai man admitted to the hospital with prolong fever, dry cough and multiple small erythematous papules on his extremities. A chest X-ray revealed diffuse miliary infiltration. Mycobacterium tuberculosis DNA was demonstrated in bronchoalveolar lavage fluid by polymerase chain reaction. Histopathology of a skin biopsy showed poorly formed noncaseating granulomatous inflammation in the lower dermis and was positive for many acid-fast bacilli. Miliary tuberculosis of the lung and skin were diagnosed. The respiratory symptom and the skin lesions improved after treatment with anti-tuberculous drugs.     

A case of hemophagocytic syndrome associated with miliary tuberculosis

We reported a case of a 76-year-female with hemophagocytic syndrome caused by military tuberculosis. The patients had complained high fever over 38.0 degrees C and anorexia. Her chest X-ray and computed tomography revealed disseminated miliary shadows in both lung fields. Laboratory examinations revealed anemia, thrombocytopenia and liver dysfunction. Bonemarrow aspirate revealed tuberculous granulomas and tubercle bacilli by acid-fast stains, and hemophagocytosis by macrophages. We diagnosed as miliary tuberculosis and tuberculosis-associated hemophagocytic syndrome, and started antituberculous and steroid therapy. After these therapy, fever, laboratory examinations dramatically improved. In this case, serum IL-18, sICAM-1, sVCAM-1 were elevated. These cytokines and adhesion molecules were reported to elevate in both hemophagocytic syndrome and tuberculosis correlating with disease activity. We conclude that IL-18, sICAM-1, sVCAM-1 may play important roles in pathogenesis of tuberculosis associated hemophagocytic syndrome.