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Wei X, Xie M, Wu S, Bao Y. The clinical features and prognostic factors of miliary tuberculosis in a high tuberculosis burden area. Ann Med 2024; 56:2356647. [PMID: 38848041 PMCID: PMC11164057 DOI: 10.1080/07853890.2024.2356647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 04/26/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Miliary Tuberculosis (TB) remains an important infectious disease that threatens human health. The clinical characteristics and prognostic factors of miliary TB are summarized in this study. METHODS The clinical information of miliary TB patients between 2010 and 2022 was retrospectively analyzed. Patients with miliary TB were characterized and compared to adverse outcomes cases. Factors independently associated with adverse outcomes were determined via multivariate logistic regression analysis. RESULTS A total of 288 patients were analyzed, including 181 with adverse outcomes. The clinical manifestations are atypical. 88.54% Of them experienced systemic symptoms, whilst 69.79% manifested respiratory symptoms. 40.97% Presented with neurologic symptoms, while 35.07% reported gastrointestinal symptoms. The major comorbidities were pharmacological immunosuppression (21.53%), pneumoconiosis (15.28%), diabetes (10.76%), and pregnancy or postpartum (7.29%). Regarding microbiology, most patients were diagnosed via sputum or Bronchoalveolar Lavage Fluid (BALF), pleural effusion, ascites, cerebrospinal fluid, urine TB-DNA, and tuberculosis culture. Meanwhile, 2.43% of patients were diagnosed via cerebrospinal fluid NGS. Independent risk factors predictive of adverse outcomes were current smoking, leukocytosis, elevated alanine aminotransferase (ALT) levels, and the combination of lymphopenia with bone marrow tuberculosis or tuberculous lymphadenitis. The accuracy of the model was validated by an area under the ROC curve of 0.753 (95% IC 0.697-0.810). CONCLUSIONS The clinical manifestations of miliary TB are atypical, and early diagnosis is challenging. The major comorbidities in miliary TB patients were pharmacological immunosuppression, pneumoconiosis, diabetes, pregnancy, and postpartum. Regarding etiological detection, multi-site and multi-type specimens should be collected for a timely diagnosis. Cerebrospinal fluid mNGS test may be a viable choice in some cases. Finally, current smoking, leukocytosis, elevated ALT levels, and the combination of lymphopenia with bone marrow tuberculosis or tuberculous lymphadenitis were identified as independent risk factors for adverse outcomes.
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Affiliation(s)
- Xiaolin Wei
- Department of Respiratory, Sichuan Taikang Hospital, Chengdu, Sichuan, P. R. China
| | - Min Xie
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, P. R. China
| | - Suji Wu
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, P. R. China
| | - Yong Bao
- Department of Respiratory, Sichuan Taikang Hospital, Chengdu, Sichuan, P. R. China
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2
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Paul SK, Ahmed S, Chakrabortty R, Paul SK, Rahman MA. Miliary tuberculosis in an immune-competent Bangladeshi man-A case report. Clin Case Rep 2023; 11:e7516. [PMID: 37305888 PMCID: PMC10256868 DOI: 10.1002/ccr3.7516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 03/11/2023] [Accepted: 05/28/2023] [Indexed: 06/13/2023] Open
Abstract
Miliary tuberculosis is a disseminated and active form of tuberculosis caused by Mycobacterium tuberculosis. It frequently affects immunocompromised patients. However, immune-competent hosts are reported rarely. Herein, we reported a case of miliary tuberculosis of a 40-year-old immune-competent Bangladeshi man presented with pyrexia of unknown origin.
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Affiliation(s)
- Susanta Kumar Paul
- Department of Respiratory MedicineBangabandhu Sheikh Mujib Medical UniversityDhakaBangladesh
| | - Shamim Ahmed
- Department of Respiratory MedicineBangabandhu Sheikh Mujib Medical UniversityDhakaBangladesh
| | - Rajashish Chakrabortty
- Department of Respiratory MedicineBangabandhu Sheikh Mujib Medical UniversityDhakaBangladesh
| | - Shamrat Kumar Paul
- Department of Physics and AstronomyClemson UniversityClemsonSouth CarolinaUSA
| | - Mohammed Atiqur Rahman
- Department of Respiratory MedicineBangabandhu Sheikh Mujib Medical UniversityDhakaBangladesh
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3
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Ghanta PR, Phatak SV, Parihar PS, Dhande RP, Reddy NG. Radiological Evaluation of a Rare Case of Rib Caries and Cold Abscess in a Young Male Patient With Miliary Tuberculosis: A Case Report With Review of Literature. Cureus 2023; 15:e35075. [PMID: 36942180 PMCID: PMC10024632 DOI: 10.7759/cureus.35075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 02/13/2023] [Indexed: 02/18/2023] Open
Abstract
Rib caries with a cold abscess is a rare presentation of tuberculosis (TB) and is tricky to diagnose. It is rarer in young patients, especially in conjunction with active miliary TB. We present one such case of a 23-year-old male patient who presented with swelling over the left lower chest. Rib caries and cold abscess were initially detected by ultrasonography and elastography. The rib involvement and the extent of the cold abscess were further evaluated on a computed tomography scan, which also showed active pulmonary miliary TB. The patient was treated by aspiration of the cold abscess and anti-tuberculosis therapy. The fact that the patient had no history of diabetes, alcoholism, human immunodeficiency virus infection, or immunodeficiency disorder increases the rarity of this case. This case highlights the role of imaging in diagnosing rib caries, cold abscess, and miliary TB.
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Affiliation(s)
- Prasanthi R Ghanta
- Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Suresh V Phatak
- Department of Radiodiagnosis, Narendra Kumar Prasadrao Salve Institute of Medical Sciences and Research Centre, Nagpur, IND
| | - Pratap S Parihar
- Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Rajasbala P Dhande
- Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Nidhi G Reddy
- Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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4
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Wetscherek MTA, Sadler TJ, Lee JYJ, Karia S, Babar JL. Active pulmonary tuberculosis: something old, something new, something borrowed, something blue. Insights Imaging 2022; 13:3. [PMID: 35001143 PMCID: PMC8743064 DOI: 10.1186/s13244-021-01138-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 12/01/2021] [Indexed: 11/26/2022] Open
Abstract
Tuberculosis remains a major global health issue affecting all countries and age groups. Radiology plays a crucial role in the diagnosis and management of pulmonary tuberculosis (PTB). This review aims to improve understanding and diagnostic value of imaging in PTB. We present the old, well-established findings ranging from primary TB to the common appearances of post-primary TB, including dissemination with tree-in-bud nodularity, haematogenous dissemination with miliary nodules and lymphatic dissemination. We discuss new concepts in active PTB with special focus on imaging findings in immunocompromised individuals. We illustrate PTB appearances borrowed from other diseases in which the signs were initially described: the reversed halo sign, the galaxy sign and the cluster sign. There are several radiological signs that have been shown to correlate with positive or negative sputum smears, and radiologists should be aware of these signs as they play an important role in guiding the need for isolation and empirical anti-tuberculous therapy.
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Affiliation(s)
- Maria T A Wetscherek
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Rd, Cambridge, CB2 0QQ, UK. .,Department of Pneumology, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babeș Street, 400000, Cluj-Napoca, Romania.
| | - Timothy J Sadler
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Rd, Cambridge, CB2 0QQ, UK
| | - Janice Y J Lee
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Rd, Cambridge, CB2 0QQ, UK
| | - Sumit Karia
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Rd, Cambridge, CB2 0QQ, UK
| | - Judith L Babar
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Rd, Cambridge, CB2 0QQ, UK
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5
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Takamatsu A, Kano Y, Tagashira Y, Kirikae T, Honda H. Current in-hospital management for patients with tuberculosis in a high-income country: a retrospective cohort study. Clin Microbiol Infect 2021; 28:383-390. [PMID: 34271181 DOI: 10.1016/j.cmi.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 07/05/2021] [Accepted: 07/05/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In Japan, most cases of tuberculosis (TB) occur among individuals aged 65 years or older. However, data on in-hospital adverse events (AEs) associated with TB management, especially in high-income nations with an ageing population, are scarce. The present study aimed to scrutinize the current TB unit practices, incidence of in-hospital AEs and predictors of in-hospital mortality. METHODS This retrospective cohort study was conducted at a tertiary care centre in Tokyo, Japan from 2012 to 2017. Inpatients with the diagnosis of TB and aged >18 years were included. Quality of in-hospital care and factors associated with in-hospital mortality were investigated using multivariate logistic regression analysis. RESULTS In total, 448 patients were enrolled. The in-hospital mortality rate was 16.7% (75/448). Miliary/disseminated TB was common (59/448, 13.2%), especially in those who died (17/75, 22.7%). Factors independently associated with in-hospital mortality were a low Karnofsky performance status score on admission (score: 40-10, adjusted odds ratio (aOR) 25.65, 95% CI 5.63-116.92 and score: 70-50, aOR 9.47, 95% CI 2.07-43.3), age over 89 years (aOR 3.68, 95% CI 1.08-12.46), Charlson Co-morbidity Index >5 (aOR 3.56, 95% CI 1.37-9.21), development of any health-care-associated infection (aOR 2.95, 95% CI 1.35-6.41), and development of any drug-related AE leading to discontinuation of anti-TB agents (seven patients were unable to resume treatment with anti-TB agents before death) (aOR 2.29, 95% CI 1.02-5.11). CONCLUSIONS In-hospital AEs (i.e. health-care-associated infection and drug-related AEs), as well as patient-related variables, were associated with in-hospital mortality among TB patients.
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Affiliation(s)
- Akane Takamatsu
- Division of Infectious Diseases, Tokyo Metropolitan Tama Medical Centre, Tokyo, Japan; Department of Microbiology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Yasuhiro Kano
- Division of Infectious Diseases, Tokyo Metropolitan Tama Medical Centre, Tokyo, Japan
| | - Yasuaki Tagashira
- Division of Infectious Diseases, Tokyo Metropolitan Tama Medical Centre, Tokyo, Japan
| | - Teruo Kirikae
- Department of Microbiology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hitoshi Honda
- Division of Infectious Diseases, Tokyo Metropolitan Tama Medical Centre, Tokyo, Japan.
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6
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Choe J, Jung KH, Park JH, Kim SH, Kim MY. Clinical and radiologic characteristics of radiologically missed miliary tuberculosis. Medicine (Baltimore) 2021; 100:e23833. [PMID: 33663042 PMCID: PMC7909107 DOI: 10.1097/md.0000000000023833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 11/19/2020] [Indexed: 01/05/2023] Open
Abstract
While chest CT provides important clue for diagnosis of miliary tuberculosis (TB), patients are occasionally missed on initial CT, which might delay the diagnosis. This study was to evaluate the clinical and radiological characteristics of radiologically missed miliary TB.Total 117 adult patients with microbiologically confirmed miliary TB in an intermediate TB-burden country were included. 'Missed miliary TB' were defined as the case in which miliary TB was not mentioned as a differential diagnosis in the initial CT reading. Clinical characteristics and radiologic findings including the predominant nodule size, demarcation of miliary nodules and disease extent on CT were retrospectively evaluated. Findings were compared between the missed and non-missed miliary TB groups. Multivariable analyses were performed to determine independent risk factors of missed miliary TB.Of 117 patients with miliary TB, 13 (11.1%) were classified as missed miliary TB; these patients were significantly older than those with non-missed miliary TB (median age, 71 vs 57 years, P = .024). There was a significant diagnostic delay in the missed miliary TB group (P < .001). On chest CT, patients with missed miliary TB had a higher prevalence of ill-defined nodules (84.6% vs 14.4%; P < .001), miliary nodule less than 2 mm showing granular appearance (69.2% vs 12.5%; P < .001), and subtle disease extent (less than 25% of whole lung field, 46.2% vs 8.7%; P < .001). Multivariable analysis revealed that only CT findings including ill-defined nodule (Odd ratios [OR], 15.64; P = .002) and miliary nodule less than 2 mm (OR, 10.08; P = .007) were independently associated with missed miliary TB.Approximately 10% of miliary TB could be missed on initial chest CT, resulting in a delayed diagnosis and treatment. Caution is required in patients with less typical CT findings showing ill-defined miliary nodules less than 2 mm showing granular appearance and follow-up CT might have a benefit.
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Affiliation(s)
- Jooae Choe
- Departments of Radiology Asan Medical Center, University of Ulsan College of Medicine
| | - Kyung Hwa Jung
- Department of Infectious Diseases, Nowon Eulji Medical Center, University of Eulji College of Medicine
| | - Joung-Ha Park
- Infectious Diseases Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Han Kim
- Infectious Diseases Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mi Young Kim
- Departments of Radiology Asan Medical Center, University of Ulsan College of Medicine
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7
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Pujari S, Gugale P, Shah D, Patel D, Gaikwad S, Desouza C, Atre A. Pulmonary tuberculosis masquerading as coronavirus disease 2019 in an HIV-infected individual with advanced immune suppression. AIDS 2020; 34:2165-2168. [PMID: 32910070 DOI: 10.1097/qad.0000000000002676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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8
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Patterson KC, Queval CJ, Gutierrez MG. Granulomatous Inflammation in Tuberculosis and Sarcoidosis: Does the Lymphatic System Contribute to Disease? Bioessays 2019; 41:e1900086. [PMID: 31588585 DOI: 10.1002/bies.201900086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 08/09/2019] [Indexed: 12/22/2022]
Abstract
A striking and unexplained feature of granulomatous inflammation is its anatomical association with the lymphatic system. Accumulating evidence suggests that lymphatic tracks and granulomas may alter the function of each other. The formation of new lymphatics, or lymphangiogenesis, is an adaptive response to tumor formation, infection, and wound healing. Granulomas also may induce lymphangiogenesis which, through a variety of mechanisms, could contribute to disease outcomes in tuberculosis and sarcoidosis. On the other hand, alterations in lymph node function and lymphatic draining may be primary events which attenuate the risk and severity of granulomatous inflammation. This review begins with an introduction of granulomatous inflammation and the lymphatic system. A role of the lymphatic system in tuberculosis and sarcoidosis is then hypothesized. With a focus on lymphangiogenesis in these diseases, and on the potential for this process to promote dissemination, parallels are established with the well-established role of lymphangiogenesis in tumor biology.
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Affiliation(s)
- Karen C Patterson
- Brighton and Sussex Medical School, 94N-SRd, Falmer, Brighton, BN1 9PX, UK.,Host-Pathogen Interactions in Tuberculosis Laboratory, The Francis Crick Institute, 1 Midland Road, London, NW1 1AT, UK
| | - Christophe J Queval
- Host-Pathogen Interactions in Tuberculosis Laboratory, The Francis Crick Institute, 1 Midland Road, London, NW1 1AT, UK
| | - Maximiliano G Gutierrez
- Host-Pathogen Interactions in Tuberculosis Laboratory, The Francis Crick Institute, 1 Midland Road, London, NW1 1AT, UK
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9
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Spectrum of imaging findings in pulmonary infections. Part 2: Fungal, mycobacterial, and parasitic. Pol J Radiol 2019; 84:e214-e223. [PMID: 31481993 PMCID: PMC6717951 DOI: 10.5114/pjr.2019.85813] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 03/11/2019] [Indexed: 01/15/2023] Open
Abstract
Chest radiography is generally the first imaging modality used for the evaluation of pneumonia. It can establish the presence of pneumonia, determine its extent and location, and assess the response to treatment. Computed tomography is not used for the initial evaluation of pneumonia, but it may be used when the response to treatment is unusually slow. It helps to identify complications, detect any underlying chronic pulmonary disease, and characterise complex pneumonias. Although not diagnostic, certain imaging findings may suggest a particular microbial cause over others. Knowledge of whether pneumonia is community-acquired or nosocomial, as well as the age and immune status of the patient, can help to narrow the differential diagnoses. The purpose of this article is to briefly review the various pulmonary imaging manifestations of pathogenic organisms. This knowledge, along with the clinical history and laboratory investigations of the patient, may help to guide the treatment of pneumonia.
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10
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Chesov D, Botnaru V. Imaging for diagnosis and management of tuberculosis. Tuberculosis (Edinb) 2018. [DOI: 10.1183/2312508x.10021217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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11
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Herreros B, Plaza I, García R, Chichón M, Guerrero C, Pintor E. Miliary Tuberculosis Presenting with Hyponatremia and ARDS in an 82-Year-Old Immunocompetent Female. Pathogens 2018; 7:E72. [PMID: 30189694 PMCID: PMC6161313 DOI: 10.3390/pathogens7030072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 08/28/2018] [Accepted: 08/28/2018] [Indexed: 01/09/2023] Open
Abstract
An immunocompetent 82-year-old female was admitted to our hospital due to fever without clear origin and hyponatremia. In the following days, an acute and bilateral pulmonary infiltrate appeared with a progressive worsening in respiratory function. Chest x-ray and CT (Computed tomography) showed bilateral reticulonodular infiltrates. Bronchoscopic aspiration and bronchoalveolar lavage (BAL), and transbronchial lung biopsy (TBBX) studies did not reveal microbiological and histopathological diagnosis. Broad-spectrum antibiotics were non-effective, and the patient died due to respiratory failure. Necropsy study revealed a miliary tuberculosis affecting lungs, liver, bone marrow, spleen, kidney, arteries, pancreas, and adrenal glands. Some weeks after the patient´s death, mycobacterial cultures from sputum, BAL and TBBX samples were positive for Mycobacterium tuberculosis.
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Affiliation(s)
- Benjamín Herreros
- Department of Internal Medicine, Hospital Universitario Fundación Alcorcón, 28922 Madrid, Spain.
- School of Biomedical and Health Sciences, Universidad Europea de Madrid, 28670 Madrid, Spain.
| | - Isabel Plaza
- Department of Nuclear Medicine, Hospital Puerta de Hierro, 28222 Madrid, Spain.
| | - Rebeca García
- Department of Internal Medicine, Hospital Universitario Fundación Alcorcón, 28922 Madrid, Spain.
| | - Marta Chichón
- Department of Internal Medicine, Hospital Universitario Fundación Alcorcón, 28922 Madrid, Spain.
| | - Carmen Guerrero
- Department of Pathology, Hospital Universitario Fundación Alcorcón, 28922 Madrid, Spain.
| | - Emilio Pintor
- School of Biomedical and Health Sciences, Universidad Europea de Madrid, 28670 Madrid, Spain.
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Abstract
CLINICAL/METHODICAL ISSUE Besides the lungs, tuberculosis (TB) can affect any organ system. In most cases, extrathoracic TB occurs in immunosuppressed patients as part of a severe illness via hematogenous spread. Extrathoracic involvement most commonly involves abdominal organs, especially the urogenital tract and less commonly the central nervous system (CNS) and the musculoskeletal system. Most frequently, computed tomography (CT) is used for detecting extrathoracic TB manifestations, except for CNS and musculoskeletal manifestations, where contrast-enhanced magnetic resonance imaging (MRI) is the gold standard. Extrathoracic manifestations of TB may be indistinguishable from inflammatory or malignant causes. Due to unspecific symptoms the diagnosis is often delayed. This article summarizes and discusses the various radiological manifestations of extrathoracic manifestation of TB. STANDARD RADIOLOGICAL METHODS Radiological modalities for screening extrathoracic TB are CT and MRI. Conventional X‑radiographs do not play a role in the diagnosis of extrathoracic TB. PRACTICAL RECOMMENDATIONS The possibility of extrathoracic TB should be considered particularly in immunosuppressed patients, such as the homeless, alcoholics or drug addicts or in patients with an immigrant background from the endemic areas of TB. The most likely site of extrathoracic TB is the abdomen; however, infections of the CNS or musculoskeletal systems and multisystem infections can also occur. In patients with suspected extrathoracic TB, radiological modalities for screening are CT, especially for abdominal infections and lymphadenopathy and MRI with contrast media for the musculoskeletal system and the CNS.
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Affiliation(s)
- D Kienzl-Palma
- Abteilung für Allgemeine Radiologie und Kinderradiologie, Universitätsklinik für Radiologie und Nuklearmedizin, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
| | - H Prosch
- Abteilung für Allgemeine Radiologie und Kinderradiologie, Universitätsklinik für Radiologie und Nuklearmedizin, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
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Abstract
Miliary tuberculosis (TB) results from a massive lymphohematogenous dissemination of Mycobacterium tuberculosis bacilli and is characterized by tiny tubercles evident on gross pathology resembling millet seeds in size and appearance. The global HIV/AIDS pandemic and widespread use of immunosuppressive drugs and biologicals have altered the epidemiology of miliary TB. Considered to be predominantly a disease of infants and children in the pre-antibiotic era, miliary TB is increasingly being encountered in adults as well. The clinical manifestations of miliary TB are protean and nonspecific. Atypical clinical presentation often delays the diagnosis. Clinicians, therefore, should have a low threshold for suspecting miliary TB. Focused, systematic physical examination helps in identifying the organ system(s) involved, particularly early in TB meningitis, as this has therapeutic significance. Fundus examination for detecting choroid tubercles offers a valuable clinical clue for early diagnosis, as their presence is pathognomonic of miliary TB. Imaging modalities help in recognizing the miliary pattern, defining the extent of organ system involvement. Examination of sputum, body fluids, image-guided fine-needle aspiration cytology or biopsy from various organ sites, needle biopsy of the liver, bone marrow aspiration, and biopsy should be done to confirm the diagnosis. Cytopathological, histopathological, and molecular testing (e.g., Xpert MTB/RIF and line probe assay), mycobacterial culture, and drug susceptibility testing must be carried out as appropriate and feasible. Miliary TB is uniformly fatal if untreated; therefore, early initiation of specific anti-TB treatment can be lifesaving. Monitoring for complications, such as acute kidney injury, air leak syndromes, acute respiratory distress syndrome, adverse drug reactions such as drug-induced liver injury, and drug-drug interactions (especially in patients coinfected with HIV/AIDS), is warranted.
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14
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Sharma SK, Mohan A, Sharma A. Miliary tuberculosis: A new look at an old foe. J Clin Tuberc Other Mycobact Dis 2016; 3:13-27. [PMID: 31723681 PMCID: PMC6850233 DOI: 10.1016/j.jctube.2016.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 03/08/2016] [Accepted: 03/10/2016] [Indexed: 11/03/2022] Open
Abstract
Miliary tuberculosis (TB), is a fatal form of disseminated TB characterized by tiny tubercles evident on gross pathology similar to innumerable millet seeds in size and appearance. Global HIV/AIDS pandemic and increasing use of immunosuppressive drugs have altered the epidemiology of miliary TB. Keeping in mind its protean manifestations, clinicians should have a low threshold for suspecting miliary TB. Careful physical examination should focus on identifying organ system involvement early, particularly TB meningitis, as this has therapeutic significance. Fundus examination for detecting choroid tubercles can help in early diagnosis as their presence is pathognomonic of miliary TB. Imaging modalities help in recognizing the miliary pattern, define the extent of organ system involvement and facilitate image guided fine-needle aspiration cytology or biopsy from various organ sites. Sputum or BAL fluid examination, pleural, pericardial, peritoneal fluid and cerebrospinal fluid studies, fine needle aspiration cytology or biopsy of the lymph nodes, needle biopsy of the liver, bone marrow aspiration and biopsy, testing of body fluids must be carried out. GeneXpert MTB/RIF, line probe assay, mycobacterial culture and drug-susceptibility testing must be carried out as appropriate and feasible. Treatment of miliary TB should be started at the earliest as this can be life saving. Response to first-line anti-TB drugs is good. Screening and monitoring for complications like acute respiratory distress syndrome (ARDS), adverse drug reactions like drug-induced liver injury, drug-drug interactions, especially in patients co-infected with HIV/AIDS, are warranted. Sparse data are available from randomized controlled trials regarding optimum regimen and duration of anti-TB treatment.
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Affiliation(s)
- Surendra K. Sharma
- Department of Medicine, All India Institute of Medical Sciences, New Delhi 110 029, India
| | - Alladi Mohan
- Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati 517 507, India
| | - Animesh Sharma
- Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110 060, India
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15
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Abstract
Thoracic imaging is widely used to detect lower respiratory tract infections, identify their complications, and aid in differentiating infectious from noninfectious thoracic disease. Less commonly, the combination of imaging findings and a clinical setting can favor infection with a specific organism. This confluence can occur in cases of bronchiectatic nontuberculous mycobacterial infections in immune-competent hosts, invasive fungal disease among neutropenic patients, Pneumocystis jiroveci pneumonia in patients with AIDS, and in cytomegalovirus infections in patients with recent hematopoietic cell transplantation. These specific diagnoses often depend on computed tomography scanning rather than chest radiography alone.
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Clinicoradiologic evidence of pulmonary lymphatic spread in adult patients with tuberculosis. AJR Am J Roentgenol 2015; 204:38-43. [PMID: 25539236 DOI: 10.2214/ajr.14.12908] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study is to evaluate the prevalence and clinicoradiologic characteristics of pulmonary tuberculosis with lymphatic involvement. MATERIALS AND METHODS A total of 126 adults with active tuberculosis who underwent CT were enrolled. A retrospective investigation of CT images focused on the presence of perilymphatic micronodules, as well as other CT features of active tuberculosis. We selected two groups of patients with micronodules according to distribution (perilymphatic vs centrilobular). We compared clinical and CT findings between the two groups. RESULTS Fifteen patients were excluded because of coexisting pulmonary disease. Among 111 patients, the prevalence of perilymphatic micronodules, galaxy or cluster signs, and interlobular septal thickening was 64 (58%), 18 (16%), and 30 (27%), respectively. Of 106 patients with micronodules, 37 and 40 were classified into the perilymphatic and centrilobular groups, respectively. Compared with the centrilobular group, the perilymphatic group had statistically significantly lower frequencies of positive acid-fast bacilli smears (32% vs 70%), consolidation (70% vs 98%), and cavitation (30% vs 60%). However, frequencies of interlobular septal thickening (41% vs 18%), galaxy or cluster signs (30% vs 0%), and pleural effusion (43% vs 20%) were statistically significantly higher in the perilymphatic group. CONCLUSION CT findings representing pulmonary perilymphatic involvement are relatively common in adults with tuberculosis. These findings may represent lymphatic spread of tuberculosis and provide an explanation for the unusual CT features of pulmonary tuberculosis mimicking sarcoidosis and the low detection of Mycobacterium tuberculosis in patients with micronodules.
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Sharma BB. Miliary nodules on chest radiographs: A diagnostic dilemma. Lung India 2015; 32:518-20. [PMID: 26628775 PMCID: PMC4587015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Kim CH, Lee J. Reply to Hong et al. Clin Infect Dis 2014; 59:142-3. [DOI: 10.1093/cid/ciu249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Lee J, Lim JK, Seo H, Lee SY, Choi KJ, Yoo SS, Lee SY, Cha SI, Park JY, Kim CH. Clinical relevance of ground glass opacity in 105 patients with miliary tuberculosis. Respir Med 2014; 108:924-30. [PMID: 24787005 DOI: 10.1016/j.rmed.2014.03.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 02/20/2014] [Accepted: 03/30/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND After the application of chest computed tomography (CT), ground glass opacity (GGO) was introduced as one of major accompanying findings of miliary tuberculosis (MT) in addition to miliary nodules. However, little is known about whether GGO is associated with the clinical manifestations and outcomes of MT. Therefore, the present study examined the clinical relevance of GGO in patients with MT. METHODS Chest radiographs and CT scans of MT patients were retrospectively reviewed. Clinical manifestations and outcomes were compared in terms of the extent of GGO revealed by chest CT. RESULTS Confirmed 105 MT patients were included. GGO was observed in 70 (67%) patients. MT patients with an extent of GGO >50% (n = 21) had symptoms of shorter duration, more frequent dyspnea, and more pronounced changes in the levels of acute phase reactants. Miliary nodules were less discernible on CT in those with an extent of GGO >50%. MT patients with an extent of GGO >50% were significantly associated with a longer hospital stay (p = 0.02) and with acute respiratory failure (p < 0.001) than those with an extent of GGO ≤ 50%. However, mortality among MT patients was not associated with the extent of GGO. CONCLUSION MT patients with an extent of GGO >50% had more rapidly progressive manifestations and a greater potential for delayed diagnosis and poorer prognosis. Nevertheless, mortality was not higher in confirmed MT patients with an extent of GGO >50% than in those with an extent of GGO ≤ 50%.
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Affiliation(s)
- Jaehee Lee
- Department of Internal Medicine, Kyungpook National University, School of Medicine, Daegu, South Korea
| | - Jae Kwang Lim
- Department of Radiology, Kyungpook National University, School of Medicine, Daegu, South Korea
| | - Hyewon Seo
- Department of Internal Medicine, Kyungpook National University, School of Medicine, Daegu, South Korea
| | - So Yeon Lee
- Department of Internal Medicine, Kyungpook National University, School of Medicine, Daegu, South Korea
| | - Keum Ju Choi
- Department of Internal Medicine, Kyungpook National University, School of Medicine, Daegu, South Korea
| | - Seung Soo Yoo
- Department of Internal Medicine, Kyungpook National University, School of Medicine, Daegu, South Korea
| | - Shin Yup Lee
- Department of Internal Medicine, Kyungpook National University, School of Medicine, Daegu, South Korea
| | - Seung Ick Cha
- Department of Internal Medicine, Kyungpook National University, School of Medicine, Daegu, South Korea
| | - Jae Yong Park
- Department of Internal Medicine, Kyungpook National University, School of Medicine, Daegu, South Korea
| | - Chang Ho Kim
- Department of Internal Medicine, Kyungpook National University, School of Medicine, Daegu, South Korea.
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Ray S, Talukdar A, Kundu S, Khanra D, Sonthalia N. Diagnosis and management of miliary tuberculosis: current state and future perspectives. Ther Clin Risk Manag 2013; 9:9-26. [PMID: 23326198 PMCID: PMC3544391 DOI: 10.2147/tcrm.s29179] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Tuberculosis (TB) remains one of the most important causes of death from an infectious disease, and it poses formidable challenges to global health at the public health, scientific, and political level. Miliary TB is a potentially fatal form of TB that results from massive lymphohematogenous dissemination of Mycobacterium tuberculosis bacilli. The epidemiology of miliary TB has been altered by the emergence of the human immunodeficiency virus (HIV) infection and widespread use of immunosuppressive drugs. Diagnosis of miliary TB is a challenge that can perplex even the most experienced clinicians. There are nonspecific clinical symptoms, and the chest radiographs do not always reveal classical miliary changes. Atypical presentations like cryptic miliary TB and acute respiratory distress syndrome often lead to delayed diagnosis. High-resolution computed tomography (HRCT) is relatively more sensitive and shows randomly distributed miliary nodules. In extrapulmonary locations, ultrasonography, CT, and magnetic resonance imaging are useful in discerning the extent of organ involvement by lesions of miliary TB. Recently, positron-emission tomographic CT has been investigated as a promising tool for evaluation of suspected TB. Fundus examination for choroid tubercles, histopathological examination of tissue biopsy specimens, and rapid culture methods for isolation of M. tuberculosis in sputum, body fluids, and other body tissues aid in confirming the diagnosis. Several novel diagnostic tests have recently become available for detecting active TB disease, screening for latent M. tuberculosis infection, and identifying drug-resistant strains of M. tuberculosis. However, progress toward a robust point-of-care test has been limited, and novel biomarker discovery remains challenging. A high index of clinical suspicion and early diagnosis and timely institution of antituberculosis treatment can be lifesaving. Response to first-line antituberculosis drugs is good, but drug-induced hepatotoxicity and drug-drug interactions in HIV/TB coinfected patients create significant problems during treatment. Data available from randomized controlled trials are insufficient to define the optimum regimen and duration of treatment in patients with drug-sensitive as well as drug-resistant miliary TB, including those with HIV/AIDS, and the role of adjunctive corticosteroid treatment has not been properly studied. Research is going on worldwide in an attempt to provide a more effective vaccine than bacille Calmette-Guérin. This review highlights the epidemiology and clinical manifestation of miliary TB, challenges, recent advances, needs, and opportunities related to TB diagnostics and treatment.
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Affiliation(s)
- Sayantan Ray
- Department of Medicine, Medical College and Hospital, Kolkata, West Bengal, India
| | - Arunansu Talukdar
- Department of Medicine, Medical College and Hospital, Kolkata, West Bengal, India
| | - Supratip Kundu
- Department of Medicine, Medical College and Hospital, Kolkata, West Bengal, India
| | - Dibbendhu Khanra
- Department of Medicine, Medical College and Hospital, Kolkata, West Bengal, India
| | - Nikhil Sonthalia
- Department of Medicine, Medical College and Hospital, Kolkata, West Bengal, India
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Sharma SK, Mohan A, Sharma A. Challenges in the diagnosis & treatment of miliary tuberculosis. Indian J Med Res 2012; 135:703-30. [PMID: 22771605 PMCID: PMC3401706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2011] [Indexed: 11/08/2022] Open
Abstract
Miliary tuberculosis (TB) is a potentially lethal disease if not diagnosed and treated early. Diagnosing miliary TB can be a challenge that can perplex even the most experienced clinicians. Clinical manifestations are nonspecific, typical chest radiograph findings may not be evident till late in the disease, high resolution computed tomography (HRCT) shows randomly distributed miliary nodules and is relatively more sensitive. Ultrasonography, CT and magnetic resonance imaging (MRI) are useful in discerning the extent of organ involvement by lesions of miliary TB in extra-pulmonary locations. Fundus examination for choroid tubercles, histopathological examination of tissue biopsy specimens, conventional and rapid culture methods for isolation of Mycobacterium tuberculosis, drug-susceptibility testing, along with use of molecular biology tools in sputum, body fluids, other body tissues are useful in confirming the diagnosis. Although several prognostic markers have been described which predict mortality, yet untreated miliary TB has a fatal outcome within one year. A high index of clinical suspicion and early diagnosis and timely institution of anti-tuberculosis treatment can be life-saving. Response to first-line anti-tuberculosis drugs is good but drug-induced hepatotoxicity and drug-drug interactions in human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) patients pose significant problems during treatment. However, sparse data are available from randomized controlled trials to define the optimum regimen and duration of treatment in patients with drug-sensitive as well as drug-resistant miliary TB, including those with HIV/AIDS.
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Affiliation(s)
- Surendra K Sharma
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India.
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Maffessanti M, Dalpiaz G. Computed Tomography of Diffuse Lung Diseases and Solitary Pulmonary Nodules. PRACTICAL PULMONARY PATHOLOGY: A DIAGNOSTIC APPROACH 2011:27-89. [DOI: 10.1016/b978-1-4160-5770-3.00003-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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