1. Miliary TB

2. History  29 y Female Ethiopian  Admitted To Medicine with 1/52 Fever, night sweating, diarrhea 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% 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 No guarding, rigidity or rebound

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

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

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

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

10. Hospital Course  Anti TB Rx + Septra was started empirically  BAL  cytology, gram stain -ve +ve AFB +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 & drop in Hb  No evidence of hemolysis Required PRBC Tx Required PRBC Tx

12. Hospital Course  Liver Bx  non specific hepatitis ? Drug reaction Vs infectious ? Drug reaction Vs infectious  Anti Tb Rx modified to INH, Rifabutin Gatifluxacin & ETB 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 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  SOB,cough,chest pain,crackles & hypoxemia & hypoxemia  Most common general symptoms  fever,wt loss, night sweating & malaise  fever,wt loss, night sweating & malaise

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

16. Miliary Tuberculosis  Progressive primary disease After a local focus is established in the lung  lymphatic then hematogenous dissemination  lymphatic then hematogenous dissemination with a predilection for spread to the most with a predilection for spread to the most vascular organs, such as the liver, spleen, vascular organs, such as the liver, spleen, bone marrow and brain 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 Reactivation of latent focus of infection with  subsequent erosion into adjoining lymphatics or blood vessels lymphatics or blood vessels Commonly occurs years or decades after primary infection Commonly occurs years or decades after primary infection

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