Acute Miliary Tuberculosis

Introduction: Miliary tuberculosis is a clinical disease resulting from hematogenous dissemination of Mycobacterium tuberculosis. Clinical manifestations are most likely subacute or chronic and are nonspecific. Risk factors may be absent. Diagnosis is confirmed through bacteriologic identification.

Case Description: A 16-year-old healthy female was admitted at our hospital with a 10-day history of daily fever, cough, night sweats and 20% estimated weight loss. Her symptoms failed to improve with previous azithromycin and amoxicillin-clavulanate treatment. Originating from Angola, she had a household positive history for bacilliferous pulmonary tuberculosis three months before symptoms onset. On physical exam she presented tachypnea, hypoxemia and crepitations throughout both lung fields. Chest radiograph showed a bilateral reticulonodular opacification pattern; laboratory tests revealed C-reactive protein of 7.92 mg/dL and erythrocyte sedimentation rate of 35mm/sec, with normal blood cell count. HIV serology was negative. Smear and culture of sputum were negative for acid-fast bacilli. Initial treatment included supportive measures, however within 72 hours she gradually developed acute respiratory distress syndrome (ARDS), requiring management at the pediatric intensive care unit through ventilatory support and higher oxygen supply. Treatment was iniciated with piperacilin-tazobactam, isoniazid, rifampicin, pyrazinamide, ethambutol and prednisolone. A bronchoalveolar lavage was performed and Mycobacterium tuberculosis was identified. Piperacilin-tazobactam was stopped with a favorable evolution. Fever and hypoxemia relapsed after prednisolone withdrawal and a more prolonged course with slow tapering was needed. Mycobacterial blood cultures were negative. No extrapulmonary disease was identified. Her overall outcome was good.

Conclusion: We present an immunocompetent patient with miliary tuberculosis and a severe acute presentation. Tuberculosis must be considered in any patient with epidemiologic risk. A negative sputum smear may be expected in miliary tuberculosis. Since this is a potentially life-threatening condition, prompt diagnosis and early intervention are keys to survival. Though controversial, steroid therapy may play an important role in patients with ARDS.