Miliary Tuberculosis; the Other Great Masquerader

1Medical University of South Carolina, Charleston, SC
2Medical University of South Carolina, Charleston, SC
3Medical University of South Carolina, Charleston, SC

Meeting: Hospital Medicine 2013, May 16-19, National Harbor, Md.

Abstract number: 389

Case Presentation:

This is a 37‐year‐old African American incarcerated man who presented with a chief complaint of abdominal pain and fever of 1‐month duration. Initial vital signs showed tachycardia to 121 bpm, blood pressure of 118/70 mm Hg, and temperature of 38.5°C. Physical exam was only significant for an ill appearing man with generalized abdominal tenderness, distention and shifting dullness. Abnormal laboratory values included sodium of 125 mmol/L, hemoglobin of 7.9 g/dL, and albumin of 2.1 g/dL. A chest x‐ray was normal. A diagnostic paracentesis was performed and peritoneal fluid showed a RBC of 208 mm3, ANC of 9 mm3, and protein of 3.7 g/dL. Peritoneal fluid culture and cytology were both negative. Blood and urine cultures, as well as antibody testing for HIV and hepatitis B and C were all negative. On hospital day 2 a CT scan of the chest, abdomen, and pelvis was ordered. Significant findings included a focal, subcarinal pneumomediastinum, tree‐in‐bud opacities in bilateral lower lung lobes and loculated ascites. A barium study confirmed a small esophageal rupture. An EGD with stent placement was performed and esophageal biopsies were obtained. At this time, the team felt the most likely diagnosis was a metastatic gastrointestinal malignancy. It wasn't until hospital day 7 that the esophageal biopsy report revealed positive staining for auramine rhodamine, concerning for mycobacterium tuberculosis infection. The patient was immediately placed on respiratory isolation and moved to a negative pressure room. Sputum and peritoneal fluid stained positive for acid fast bacilli. The patient was started on rifampin, isoniazid, ethambutol, and pyrazinamide (RIPE therapy). Within 48 hours of starting RIPE therapy, the patient defervesced. He was discharged back to prison in improved condition.

Discussion:

Miliary, or disseminated tuberculosis, refers to hematogenous spread of the microorganism resulting in metastatic organ spread. The CDC reported that in 2011 only 4% of TB cases in the United States were military. Although it is a rare entity, it must be considered, because when left untreated, it is 100% fatal. The presentation can range from sub‐acute mild illness to fulminant sepsis or ARDS. The most common signs and symptoms (fever, weight loss, night sweats and fatigue) are nonspecific and approximately 20% of cases are diagnosed postmortem. Our patient's status as a prisoner was an important risk factor. Treatment in this case was delayed and health care workers were put at risk because of an inappropriately low index of suspicion.

Conclusions:

Recognizing unusual presentations of tuberculosis is an important skill for hospitalists to acquire.

Pneumomediastinum.

To cite this abstract:

Pride P, Cuoco T, Duckett A. Miliary Tuberculosis; the Other Great Masquerader. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 389. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/miliary-tuberculosis-the-other-great-masquerader/. Accessed September 16, 2019.

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