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Miliary TB

Miliary TB. History. 29 y Female Ethiopian Admitted To Medicine with 1/52 Fever , night sweating , diarrhea No contact with similar case No cough , SOB , Chest pain. History. Diarrhea non bloody 2-3 /day No jaundice , upper or lower GI bleeding No dysphagia , odynophagia

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Miliary TB

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  1. Miliary TB

  2. History • 29 y Female Ethiopian • Admitted To Medicine with 1/52 Fever , night sweating , diarrhea • No contact with similar case • No cough , SOB , Chest pain

  3. History • Diarrhea non bloody 2-3 /day • No jaundice , upper or lower GI bleeding • No dysphagia , odynophagia • No recent travel • Pre immigration exam  N

  4. History • PMH : -ve • No medication • Non smoker & No ETOH • SR : decrease hearing & tinnitus

  5. Examination • Febrile 38.5 BP 110/65 HR 95 RR 18 Sat 95% • No lymphadenopathy , clubbing • Chest : clear , good breath sound • CVS : S1+S2+0 • Abd : Mild diffuse tenderness No guarding , rigidity or rebound

  6. Investigation • CBC : WBC 5 Lymph .3 Hb 65 MCV 69 RDW 16 Plt 85 PTT & INR N • Na 133 K 3.2 Co2 16 Creat & BUN N • AST 160 , ALT 140 Alk Phos 60 Billirubin N

  7. Hospital Course • Admitted to H4 for Hydration & work up • CT Abdomen Multiple LN paraaortic , celiac Multiple nodules in spleen Thickening in small bowel & ascending colon CT guided Bx was planned

  8. Hospital Course • Chest Medicine was consulted Increased SOB & O2 requirement • O/E febrile 39.5 BP 100/55 HR 140 RR 22 Sat 93% on 7 l O2 Chest : Bilateral coarse crackles CVS: S1+S2+0 II /VI ESM LSB JVP 3 cm ASA

  9. Hospital Course • CBC : Hb 65 CD4 25 • ABG PH 7.38 PAO2 90 PCO2 30 Hco3 20 • Blood ,sputum C/S –ve • Empiric Abx for ? Pneumonia Cefotaxime & azithromycine

  10. Hospital Course • Anti TB Rx + Septra was started empirically • BAL  cytology , gram stain -ve +ve AFB • CT guided LN Bx necrotizing granuloma • HIV +ve

  11. Hospital Course • Clinical improvement within few days • Worsening elevation liver enzyme & drop in Hb • No evidence of hemolysis Required PRBC Tx

  12. Hospital Course • Liver Bx non specific hepatitis ? Drug reaction Vs infectious • Anti Tb Rx modified to INH , Rifabutin Gatifluxacin & ETB • Discharged with plan to start HAART Rx after treating TB

  13. Miliary Tuberculosis • Used to be pathological then radiological term 1700 by John Jacobus Manget nodular surface of that look like Millet seeds • Currently used denote all forms of progressive, widely disseminated hematogenous TB, even if the classical pathologic or radiologic findings are absent. • 20% ot TB cases diagnosed postmortem in the pre antimicrobial era were miliary fallen to 0.7% after

  14. Miliary Tuberculosis • Variable presentations  from non specific symptoms to septic shock & ARDS • Most common pulmonary manifestations SOB,cough ,chest pain ,crackles & hypoxemia • Most common general symptoms fever ,wt loss , night sweating & malaise

  15. Miliary Tuberculosis • Delayed & missed diagnosis is usually due to Non specific symptoms Lack of suspicion Delay in culturing all accessible body fluid • Can arise  progressive primary infection reactivation of a latent focus with spread  rarely via iatrogenic origin.

  16. Miliary Tuberculosis • Progressive primary disease After a local focus is established in the lung  lymphatic then hematogenous dissemination with a predilection for spread to the most vascular organs, such as the liver, spleen, bone marrow and brain

  17. Miliary Tuberculosis • Progressive primary disease Occurs when these distant foci fail to heal and is typically seen within the first six months after primary infection • Many patients have underlying medical conditions impairing the development of effective cell mediated immunity

  18. Miliary Tuberculosis • Reactivation of a latent focus Reactivation of latent focus of infection with subsequent erosion into adjoining lymphatics or blood vessels Commonly occurs years or decades after primary infection

  19. Miliary Tuberculosis • Radiological Investigation CXR faint reticulonodular infiltrate Pleural reactions  Hilar or mediastinal adenopath CT multiple small nodules septal thickening non specific

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