Mortality from Quantiferon‐Negative Miliary Tuberculosis: Missed Opportunities?

1Cleveland Clinic Foundation, Cleveland, OH

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 420

Case Presentation:

A 69‐year‐old woman presented with 3 months of fever and dyspnea that remained undiagnosed after an extensive workup in a local hospital. History was pertinent for remote partially treated latent tuberculosis (TB), diabetes, and remote pancreatic cancer treated with Whip‐ple surgery and chemotherapy. Chest roentgenograms (CXR) and computed tomography (CT) consistently revealed diffuse reticulonodular infiltrates. A lung biopsy obtained through bronchoscopy demonstrated necrotizing granulo‐mas, confirmed by open lung biopsy. All causes of hyper‐sensitivity pneumonitis were ruled out. Repeated infectious, malignancy, and fungal investigations were also unrevealing. Tuberculosis interferon gamma release assay (Quanti‐FERON) and HIV serology were negative. Multiple courses of broad‐spectrum antibiotics and a course of steroids for presumed sarcoidosis were unsuccessful; instead, she had clinical deterioration and developed seizures, lethargy, and acute hepatitis. Cerebrospinal fluid (CSF) studies revealed lymphocytic pleocytosis with low glucose and high protein. Brain MRI showed widespread 2‐ to 5‐mm parenchymal brain enhancement. Echocardiogram showed no vegetation/thrombus. Liver biopsy showed granulomas. On transfer to our tertiary medical center, all previously taken cultures eventually revealed positive acid‐fast bacilli (AFB) in the blood, CSF, and bronchial washings, consistent with disseminated TB. On the final culture report, M. tuberculosis was pansensitive. Despite initiation of antituberculosis therapy, she died secondary to multiorgan failure.

Discussion:

Although TB remains epidemiologically burdensome worldwide; it is a relatively rare entity in the United States, with the Centers for Disease Control reporting 11,545 cases in 2009. Disseminated TB is associated with malnutrition, HIV/AIDS, alcoholism, diabetes, chronic kidney failure, immunosuppressive drugs, and organ transplantation. Diagnosis can be challenging because of nonspecific clinical presentations and low incidence. CXR may reveal a miliary pattern, as seen with this case. TheMantoux test and QuantiFERON can be falsely negative in immunosuppression. Although AFB smears and cultures confirm the diagnosis, the yield is inconsistent and varied across sample sites. Tubercles remain the histopathological hallmark of miliary TB. Granulomas are nonspecific and can be observed in sarcoidosis, hypersensitivity pneumonitis, aspiration pneumonia, and fungal infections. Mortality rates in miliary TB are as high as 20% with central nervous system involvement as an independent predictor.

Conclusions:

The hospitalist should have a high clinical suspicion for TB in immunosuppressed patients in whom QuantiFERON can be negative. Empiric antituberculosis therapy should be promptly started. Final culture results can take up to 6–8 weeks, which can delay the diagnosis and timely treatment.

Disclosures:

M. Velez ‐ none; V. Velez ‐ none; M. Auron ‐ none

To cite this abstract:

Velez M, Velez V, Auron M. Mortality from Quantiferon‐Negative Miliary Tuberculosis: Missed Opportunities?. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 420. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/mortality-from-quantiferonnegative-miliary-tuberculosis-missed-opportunities/. Accessed September 19, 2019.

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