Authors Mohamad Badr Jandali, MD & Deepika Polineni, MD Kansas University Medical Center, Department of Pulmonary and Critical Care Medicine
Case
A 52-year-old male from Mexico with advanced alcoholic liver disease
presented with confusion, cough, and mild hemoptysis. The patient
endorsed daily alcohol consumption and a prior smoking history, but
denied recreational drug abuse. Vitals showed a temperature of 38.1 C
and labs showed acute on chronic hyponatremia to 119 mmol/L and severe
thrombocytopenia to 4 K/UL. His chest X-ray (image A) and CT scan (image
B) are shown below.
Images
Question
What is the most likely diagnosis?
A. Miliary Tuberculosis B. Septic emboli C. Malignant metastases D. Sarcoidosis
Answer
Answer: A. Miliary Tuberculosis
Discussion
These are classic radiographic findings of miliary tuberculosis (TB).
A miliary pattern is characterized by innumerable small diffuse
nodular densities throughout lung fields, usually 1-3mm in diameter[1].
In the nineteenth century, TB was called the white plague as patients
became extremely pale before death. History and clinical suspicion
should guide the work up of miliary radiographic pattern. In our
patient, a diagnosis of TB was established with a positive T-spot
followed by positive peritoneal fluid AFB cultures.
The term miliary opacities
comes from the appearance of the millet seed, a common grain grown
around the world (image C). While the radiographic miliary pattern is
most commonly linked to tuberculosis, but it can actually be seen in
many other diseases: infections such as tuberculosis, Haemophilus influenza, Mycoplasma pneumonia,
and fungal infections [2]; metastatic malignancy such as papillary
thyroid cancer, renal cell carcinoma, lymphoma, and osteosarcoma [3];
and other conditions including sarcoidosis, hypersensitivity
pneumonitis, and pneumoconiosis.
The treatment of miliary or
disseminated tuberculosis is similar to that of pulmonary TB. It starts
with 4 drug intensive phase therapy with Isoniazid, Rifampin,
Pyrazinamide and Ethambutol for 8 weeks followed by 18 weeks of 2 drug
continuation therapy with Isoniazid and Rifampin. The role of adjunct
corticosteroid therapy remains controversial, but it should be
considered especially when CNS involvement is present. Seeking an expert
opinion is strongly recommended, as many of these patients require
individualized therapy regimens due to certain comorbidities. Prognosis
largely depends on baseline comorbidities, treatment adherence and organ
involvement where CNS disease seems to predict higher mortality [4].
Unfortunately, our patient's condition worsened despite therapy and he
died from multiorgan failure.
Furqan M and Butler J. Miliary pattern on chest radiography: TB or not TB? Mayo Clin Proc 2010. 85(2): 108.
Koutsopoulos AV, et al. Is a miliary chest pattern always indicative
of tuberculosis or malignancy? Respiration, 2006; 73(3): 379-81.
Nahid P, et al. Official American Thoracic Society / Centers for
Disease Control and Prevention / Infectious Diseases Society of America
Clinical Practice Guidelines: Treatment of drug-susceptible
tuberculosis. Clin Infect Dis 2016; 63(7): e147-95.
