1. Miliary TB

2. History
57 y/o Russian male with history of fever and elevated LFTs after having sinus surgery for recurrent polyps 6 months ago
Extensive work up for source of fever including bone marrow biopsy, negative for infectious process

3. History
Initially diagnosed with Wegener’s granulomatosis at OSH and placed on prednisone with temporal resolution of symptoms and normalization of LFTs
While on prednisone had recurrence of fever and was admitted to The University of Miami Hospital for further work-up

4. Initial Liver Biopsy (OSH)
Compatible with granulomatous hepatitis
Fungal, bacterial and AFB stains and cultures were negative

5. Laboratory Testing Multiple negative blood cultures
CMV, HCV, EBV, HSV, HBV PCR negative
Aspergillus, endemic fungal serologies, Bartonella serology, Cryptococcal antigen, Histoplasma antigen negative
Myeloperoxidase and proteinase antibodies negative

6. Laboratory Testing ANCA negative Alk Phos 192 ANA negative Alb 1.8
AST/LT 101/ TB 0.6
Cr 1.1
IgG Iron 13
Ferritin Wbc 12.6
Plat Hb/Hct 8.8/26
ESR 144

7. Initial Imaging Abdominal U/S: hepato-splenomegaly
Abdominal MRI: numerous nodular foci throughout the liver
CT chest: diffuse infiltrating process involving the liver and linear opacification RLL

9. Diagnosis

10. Laparoscopic Liver Biopsy

11. Laparoscopic Liver Biopsy

12. Laparoscopic Liver Biopsy

13. Laparoscopic Liver Biopsy
Extensive necrotizing granulomatous inflammation
Bacterial, fungal, and AFB stains were again negative

14. Diagnosis Liver specimen AFB cultures positive for MTB
Currently on 4 drug anti-tuberculosis therapy
Recent admission to UMH for adrenal insufficiency caused by abrupt discontinuation of prednisone