A 60 y.o. woman with a hx of hypertension presents with fever and fatigue
She has been seen once in an urgent care and diagnosed with URI; COVID negative.
her cxr was read as normal and she was discharged home with presumed URI
she returned several days later with fever and fatigue. What does she have?
Our patient had military tuberculosis which is caused by hematogenous spread of Mycobavcterium tuberculosis bacilli. The term was first coined by John Manget in 1700 while describing the nodules in the lung of a tuberculous patient as similar to millet seeds. The Latin word miliarius refers to millet seed. iliary Miliary tuberculosis can cause fever, hypotension septic shock and death. Patients who are immune compromised are at significant risk for miliary tuberculosis. In 10-30% of cases of miliary tuberculous meningitis occurs.
millet seeds are approximately 2mm
TBC can be either pulmonary or extrapulmonary with puulmonary tuberculosis being the most common. Over a million people die from tuberculous every year across the world.
Extrapulmonary tuberculosis involves organs other than the lungs (the lymph nodes, abdomen, skin bones meninges. It can cause pancytopenia, mycotic aneursyms and pericarditis even without pulmonary involvement.
Musculoskeletal involvement accounts for 10% of cases of extrapulmonary TB. Spine involvement, Pott’s disease is the most often found followed by septic arthritis.
pott’s disease is involvement of the spine with tuberculosis
Abdominal TB can occur as hepatic, intestinal or peritoneal involvement. The presentation is often fever, jaundice and hepatospenomegaly.
Skin manifestations of tuberculosis- occurs in the form of macules or papules. Skin presentations are common in individuals with HIV and a CD4 count of <200.
Our patient Our patient had an interferon gamma release assay that was positive two months pta. Apparently no one saw it. The first person to find it was the ED resident on her third visit. The patient was persistently hypoxia prompting a CT which was read as mild pulmonary edema. She had a complicated course with sepsis, renal failure and persistent hypoxia. She remains intubated and is on dialysis.
PEARL: the gamma release assay is useful in individuals who have been vaccinated with BCG. Their skin tests are not useful and remain positive.
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Sharma S, Mohan A, Sharma A, et al. Miliary tuberculosis: new insights into an old disease. Lancet Infect Dis. 2005 Jul;5(7):415-30.