Cryptic miliary tuberculosis

Delayed diagnosis of multiple systemic disseminated tuberculosis: A case report

RATIONALE

The clinical manifestations in patients with disseminated tuberculosis (TB) are nonspecific and may present challenges for early diagnosis.

PATIENT CONCERNS AND DIAGNOSES

We describe the case of a 44-year-old man who presented with abdominal pain and discomfort for more than a month. He had undergone surgery for a chest wall abscess 9 months ago. Computed tomography scans showed a miliary pattern in the lung and multiple abscesses in the liver, spleen, left psoas major muscle, skin, and soft tissue, with rim enhancement. Mycobacterium tuberculosis was detected in the drainage fluid of the abscesses and surgical slices, and disseminated TB was diagnosed.

INTERVENTIONS AND OUTCOMES

With anti-tuberculosis therapy, the abscesses were gradually absorbed and all cultures were negative.

LESSONS

The patient exemplifies the difficulty of the early diagnosis of disseminated TB. Disseminated TB should be considered first in patients with multisystem illness, and then evidence should be pursued relentlessly to establish a diagnosis.

Corticosteroid-induced exacerbation of cryptic miliary tuberculosis to acute respiratory distress syndrome: A case report

RATIONALE

Steroid is known to cause generalized immunosuppression, thereby increasing the risk of new infection or recurrence of tuberculosis. However, corticosteroid as a culprit for exacerbation of miliary tuberculosis-from a cryptic to an overt form-has rarely been described in the literature. Moreover, miliary tuberculosis is hardly diagnosed in a living patient as a primary cause of ARDS even in TB-endemic regions. To the best of our knowledge, this is the first case of a steroid-induced progression of cryptic miliary tuberculosis to ARDS, provided with clear depiction of its radiologic evolution.

PATIENT CONCERNS

A 36-year-old male was treated with corticosteroid under suspicion of adult onset still's disease for six-week history of fever. Within 2 weeks since the initiation of corticosteroid therapy, the patient experienced acute exacerbation of cryptic miliary tuberculosis, which evolved to an overt form, appearing as miliary nodules on both chest radiograph and HRCT. Then, his condition suddenly deteriorated to severe acute respiratory distress syndrome in less than a day.

DIAGNOSIS

The final diagnosis was miliary tuberculosis complicated by severe acute respiratory distress syndrome.

INTERVENTIONS

The patient was placed on classic quadruple anti-TB treatment (isoniazide, ethambutol, rifampin, and pyrazinamide).

OUTCOMES

His fever subsided in about 6 weeks and 3 consecutive sputum AFB smears collected on different days were confirmed negative. Diffuse infiltrates on his chest x-ray were completely resolved.

LESSONS

The case described here draws a clinical and radiological picture of how an occult form of miliary TB evolved to an overt form with use of steroid, and then suddenly progressed to acute respiratory distress syndrome in an immunocompetent young male. This raises awareness on the potential risk of using corticosteroid in patients with cryptic miliary TB. There is formidable challenge in the diagnosis of miliary TB, especially in the early stages. Atypical or even normal outcomes of clinical, microbiochemical, and radiologic evaluation should not be overlooked and dedicated diagnostic work-up should be performed. For equivocal cases, active surveillance with serial radiographs can be helpful.

Review of literature on disseminated tuberculosis with emphasis on the focused diagnostic workup

Disseminated tuberculosis (TB) is a life-threatening disease resulting from the hematogenous spread of Mycobacterium tuberculosis. The diagnosis is challenging owing to its subtle nonspecific clinical presentation, which usually reflects the underlying organ involved. Besides, tools for confirmatory laboratory diagnosis are limited. Therefore, a high index of suspicion is required for early diagnosis. Miliary pattern on chest radiography is a common finding that has an important role in the early detection of the disease. Nevertheless, approximately 10%-15% of patients have normal chest radiography. Although abnormalities are present, basic hematologic and biochemical tests as well as tuberculin skin test are nonspecific for the diagnosis. Imaging studies are helpful adjunct tools for disseminated TB as they can help determine the involved sites and guide technicians to obtain appropriate specimens for diagnosis. Clinical confirmation of the diagnosis of disseminated TB is usually based on bacteriological or histological evidence. Response to first-line anti-TB drugs is good as evidenced by many reports. This review aims to present a current update on disseminated TB with emphasis on the diagnostic workup of this devastating condition.