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In this report we describe a patient with miliary tuberculosis who presented with the adult respiratory distress syndrome. The diagnostic problems are discussed and the value of transbronchial lung biopsy is emphasized. Our experience with this patient stresses the need for maintaining a high index of suspicion for treatable causes of adult respiratory distress syndrome.
No difference in the number of serious adverse events was reported in previous clinical trials in rheumatoid arthritis (RA) and inflammatory bowel disease (IBD) patients treated with TNF-alpha blockade, but a patient died because of disseminated tuberculosis. A tuberculosis reactivation in a patient with IBD and anti-TNF-alpha treatment has been recently reported. Very recently 70 cases of tuberculosis were reported from the FDA Adverse Event Reporting System. We report a case of pulmonary miliary tuberculosis in a RA patient treated with TNF-alpha blockade. The important role of TNF-alpha in defence against tuberculosis and possible mechanisms of anti-TNF-alpha agents impairing tuberculosis immune response are discussed.
We report the development of miliary tuberculosis in a 7-year-old boy with severe combined immunodeficiency (SCID), whose immune system had been only partially reconstituted by haploidentical bone marrow transplantation. Although alpha beta and gamma delta T cells were of donor origin, alpha beta T cells in this patient showed defective interleukin-2 (IL-2) production, impaired IL-2 responsiveness and decreased cytolytic activity. However, gamma delta T cells could exhibit enough cytolytic activity after incubation with IL-2. Despite the presence of disseminated infection, C-reactive protein (CRP) remained negative. IL-2 therapy aggravated the disseminated tuberculosis though gamma delta T cells were supposed to be activated, and concurrently CRP became positive. These findings suggest that gamma delta T cells have no more than limited immunological roles in mycobacterium tuberculosis infection.
Gastrointestinal manifestations of both Behçet's disease and intestinal tuberculosis include the signs and symptoms of abdominal pain, weight loss, fever, vomiting, diarrhea and palpable mass in the right lower quadrant. We report the case of a male patient with Behçet's disease who had multiple ileal perforations due to miliary tuberculosis. It was suspected that the perforations were due to intestinal manifestation of Behçet's disease, but the final pathology report and chest X-ray one week after surgery demonstrated the presence of miliary tuberculosis. To our knowledge, this is the first reported case of Behçet's disease with intestinal perforation due to miliary tuberculosis.
CONTEXT: Tuberculosis is an important public health issue. The Brazilian government reported 78,460 new cases in 1999. Miliary tuberculosis is a severe form of this disease. OBJECTIVE: To report on an uncommon clinical presentation of miliary tuberculosis in a child. CASE REPORT: A 5-year old boy presented in the emergency room with fatigue and weight loss. He had had Staphylococcus aureus pneumonia 7 months before. Chest radiography revealed lobar consolidation and miliary pattern associated with small cavities in both upper lobes. Antibiotic therapy was started. The sputum was positive for acid-fast bacilli and hence the treatment recommended for tuberculosis (rifampicin, isoniazid [INH], pyrazinamide) was started. The patient was treated for 9 months and at the end of the follow-up period he had made a complete clinical recovery. CONCLUSION: Although in some particular cases sputum can be positive for acid-fast bacilli in children, limitations to the sputum test have forced pediatricians to base tuberculosis diagnosis on epidemiological data, clinical findings and radiographic pattern. In this particular case, we hypothesize that the sputum bacillus test was positive because bacilli grew inside residual pneumatoceles that were produced during previous pneumonia.
Pathological analysis was made on 28 cases in relation to aging process and to onset of miliary tuberculosis. They were classified into the following 4 groups. (1) Early dissemination (2) Dissemination from secondary complex lesion (3) Recurrence and dissemination from stable tuberculous lymph node lesions (4) Late dissemination. The majority of the cases (57.1%) was of late dissemination irrespective of the age of patient. In 16 cases over 60 years of age, two cases which appeared on the immunological memory defect, were thought to develop from so-called secondary complex lesion. Nearly one third (5) of cases over 60 years of age developed miliary tuberculosis from the relapsed lymph node tuberculosis in association with primary complex. These forms were seldom reported in the past and were thought to refer to the immunological defect in aging process. The findings will be published in detail elsewhere.
A seven-month-old girl with miliary tuberculosis (Tbc) admitted to hospital due to development of acute dyspnoea and cyanosis at the end of third month of anti-Tbc therapy. Pneumothorax was evident at right lung with the chest radiography. A chest tube placed under water seal was applied. The patient healed up and then discharged. One week later, the patient admitted to hospital again, with same complaints due to pneumothorax at the same hemithorax. Same treatment was applied to the patient. Anti-Tbc therapy was stopped at the end of 12th month. Although, pneumothorax is a rare life-threatening complication of miliary Tbc, it's not seen only on admission or soon after beginning of the therapy, but it can be seen several months later during treatment. We want to report this case. That is the first case in which pneumothorax developed during therapy of an infant with miliary Tbc.
We report a case of miliary tuberculosis (MTB) occurring after extracorporeal shock-wave lithotripsy in a 51-year-old man. The MTB was complicated by pancytopenia and CD4(+) T-lymphocytopenia, which was responsible for Pneumocystis carinii pneumonia. Hematological parameters returned to normal in response to antituberculous treatment.
A 52-year-old woman visited a physician on Oct. 17, 1995 because of dizziness, general fatigue and a slight fever. A Chest X-ray film showed micronodulous and infiltrative shadows in the bilateral upper lung fields. Liver dysfunction was also recognized. As dyspnea and hypoxemia progressed very rapidly, the patient was intubated and kept under mechanical ventilation. A diagnosis of miliary tuberculosis with adult respiratory distress syndrome (ARDS) was made based on the detection of acid-fast bacilli from sputum obtained from the endotracheal tube. She was admitted to our hospital on Oct. 24, 1995 receiving anti-tuberculous drugs combined with high-dose methylprednisolone. As disseminated intravascular coagulation (DIC) and acute pancreatitis also developed, gabexate mesilate was added to the preceding therapy. This combination therapy was effective and the patient gradually improved. Two months after the admission, aneurysms of the abdominal aorta and left renal artery were discovered. As the size of the aneurysms had been increasing along with abdominal and low back pain, the patient was transferred to an other hospital for surgical treatment. She underwent a successful operation for pseudoaneurysms, the etiology of which was tuberculosis according to pathological findings and detection of acid-fast bacilli from the resected specimens. This is the 10th case of tuberculous aneurysm of the aorta which was successfully operated on in Japan. ARDS, DIC and aneurysm occur rarely as complications of miliary tuberculosis, but they are life-threatening, and lead to a serious prognosis if untreated. Early diagnosis of miliary tuberculosis and tuberculous aneurysm is very important for a good outcome.
We present clinical, bacteriologic, and pathological findings for four patients with AIDS and cutaneous miliary tuberculosis. All patients had generalized tuberculosis with hematogenous dissemination to multiple organs including the skin. Microscopic examination of the skin lesions revealed ill-formed or no granulomata, extensive necrosis, and numerous acid-fast bacilli. Mycobacterium tuberculosis was detected in the skin lesions by cultures for three patients and by polymerase chain reaction for one. Three of the isolates were resistant to at least isoniazid and rifampin, and one was susceptible to these drugs. The outcome was rapidly fatal for the three patients with multidrug-resistant tuberculosis. This report draws attention to the reappearance of a once-rare manifestation of disseminated tuberculosis which, in the setting of advanced human immunodeficiency virus disease, may offer the first indication of infection with multidrug-resistant M. tuberculosis and a poor prognosis.
A 74-year-old woman with miliary tuberculosis had moderately severe hyponatremia due to inappropriate secretion of antidiuretic hormone (SIADH) and very severe thrombocytopenia without other hematologic abnormalities. She was treated with isoniazid, rifampin, ethambutol, prednisone, vincristine and fluid restriction and recovered completely. The SIADH may have been a response by the posterior pituitary to a decrease in intravascular volume resulting from the extensive pulmonary disease or associated hypoxia, or the tuberculous lung may have released ADH or an ADH-like substance. The thrombocytopenia may have resulted from a direct or indirect toxic effect of infection or, less likely, the tuberculosis may have activated latent idiopathic thrombocytopenic purpura.
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.
An 82-year-old man with the chief complaint of anorexia was referred on suspicion of pulmonary tuberculosis. He had undergone thyroidectomy because of thyroid cancer 5 years ago, had taken levothyroxine sodium, and had kept plasma level of thyroidal hormone within normal range. He had never pointed out hyponatremia. On laboratory findings on admission, serum natrium level was 125 mEq/l. A chest X-ray film showed the infiltration in both lower lung fields, and a chest CT scan revealed a miliary pattern in both lungs. Tubercle bacilli were detected from the sputum by the Ziehl-Neelsen staining. Antituberculous drugs were started. On 5th hospital day, he developed consciousness disturbance, and the serum level of natrium and osmolarity was 103 mEq/l and 250 mOsm /kgH2O, respectively, while plasma ADH level was increased to 5.9 pg/ml, and urine level of natrium and osmolarity was 123 mEq/l and 394 mOsm/kgH2O, respectively. His mental disturbance and hyponatremia gradually improved by supplementing NaCl. We diagnosed this case as SIADH associated with miliary tuberculosis. SIADH should be considered when hyponatremia was occurred in the case of miliary tuberculosis.
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Hypercalcaemia and hypercalciuria were diagnosed in a 21-week-old boy with miliary tuberculosis. The tuberculosis was treated with isoniazid, rifampin and streptomycin. After 2 months, streptomycin was replaced by ethambutol. The hypercalcaemia was treated initially with prednisone, which decreased the serum 1.25 (OH)2 cholecalciferol level but the serum calcium level remained unaltered. After calcium and vitamin D restriction, the serum calcium level normalized within 1 day. The patient's tuberculosis was treated and he remains well.
The case of a male preterm baby who had congenital miliary tuberculosis with multiple intestinal perforations is reported. The patient was successfully treated with antituberculosis chemotherapy and surgical repair along with other supportive therapy. This is one of the rarest cases of the type described here.