Chest radiographs may show multiple bilateral small opacities, termed miliary infiltrates because of their resemblance to millet seeds. Jon S. Friedland, in Infectious Diseases (Third Edition), 2010. In the past, miliary tuberculosis was mainly seen in young children, as an early consequence of initial infection and bacillemia; currently, however, except among HIV-infected persons, it is more common among older persons, as a result of endogenous reactivation and bloodstream invasion. Bacterial infections generally do not produce this fine nodular pattern of pulmonary involvement. As noted previously, HIV-infected patients may not be able to form granulomas; thus, instead of discrete individual lesions, a diffuse uniform pattern of infiltration may be seen. Radiographic changes may only develop after a patient has been admitted to hospital, so patients must be reassessed frequently. You will be subject to the destination website's privacy policy when you follow the link. Combinations of bronchoalveolar lavage and transbronchial biopsy would be expected to have a high yield.307 Other potential sites for biopsy include liver and bone marrow, each of which has a high likelihood of showing granulomas (70% to 80%), but only a 25% to 40% chance of providing bacteriologic confirmation; urine cultures may be positive in up to 25% of patients.305,306 Selection of other potential sources of diagnostic material should be guided by specific findings. 30.10). Widespread macular and papular skin lesions (tuberculosis miliaris disseminata) are suggestive of miliary infection. Treatment used to be 9 months of daily INH. Miliary infiltrates on chest X-ray or FUO should raise the possibility of miliary TB. The median age at presentation is 10.5 months, with about half of cases occurring in those younger than 1 year. The U.S. Food and Drug Administration has issued a public statement external icon related to nitrosamines external icon impurities in rifampin and rifapentine, two important anti-tuberculosis (TB) medications. Tuberculosis (TB) is a potentially serious infectious disease that mainly affects your lungs. Other abnormalities may be present as well. Larger nodules and a pulmonary focus occur in approximately one-third of patients. Surgery is required for the following: To drain empyema, cardiac tamponade, or CNS abscess To close bronchopleural fistulas To resect infected bowel To decompress spinal cord encroachment Despite the disseminated disease, the miliary nodules are interstitial. Larger nodules and a pulmonary focus occur in approximately one-third of patients. 17.1) results from hematogenous dissemination and almost invariably leads to a dramatic febrile response with night sweats and chills. Miliary TB is the most common form of disseminated disease and usually occurs early after the infection, within the first 2 to 6 months, and may represent uncontrolled primary infection in children. Pulmonary tuberculosis (TB) is a contagious, infectious disease that attacks your lungs. On occasions, ‘miliary’ tuberculosis occurs without the classical chest X-ray appearances; so-called ‘cryptic’ disseminated tuberculosis. Common antibiotics are: isoniazid ethambutol pyrazinamide rifampin About 10% of latent infections progress to active disease which, if left untreated, kills about half of those affected. Miliary tuberculosis is a descriptive radiological diagnosis which has historically depended upon a plain chest radiograph showing numerous 1–2 mm well-defined nodules scattered throughout both lung fields (see Figure 40.7). Disseminated or miliary tuberculosis is a severe form of tuberculosis which results from hematogenous spread of tubercle bacilli which may occur if they reach the circulation via the lymphatics. The chest radiograph typically shows the classic “miliary” pattern of diffuse small nodules (Figure 31-6). This difference in cause helps explain some of the clinical and radiologic differences in the two conditions. Generally, treatment of miliary tuberculosis is similar to the treatment of pulmonary tuberculosis. The shift in age-specific incidence presumably has been caused at least in part by the paucity of new infections in relation to the number of endogenous reactivations in the United States. Miliary TB with meningeal involvement may require prolonged treatment (up to 12 mo). Signs or symptoms of meningitis or peritonitis are found in 20% to 40% of patients with advanced disease. Nocardia, previously regarded as a fungus, is now considered to be a gram-positive bacterium that rarely causes infection in normal patients but is an opportunistic infection in patients who are immunosuppressed. To those who first described these appearances 100 years ago, the nodules looked like millet seeds. Factors involved in the development of miliary infection include delay in diagnosis, impaired immune responses, mycobacterial virulence factors, mycobacterial load and the number of organisms able to gain entry to the bloodstream. Choroidal tubercles 0.5–3.0 mm in diameter are essentially diagnostic of miliary disease (Fig. The yield of sputum AFB microscopy and culture is low, averaging 30% and 50%, respectively, with variations across the reported series. The acute epidemic form of histoplasmosis produces the radiologic appearance of larger, ill-defined nodules, similar to that of bronchopneumonia (see Chapter 16). The findings on initial chest radiographs are often subtle and may be clear-cut only in retrospect after 3 months of follow-up. Miliary TB usually has an insidious manifestation consisting of fever, weight loss, night sweats, and little in the way of localizing symptoms or signs. With progressive pulmonary disease, respiratory distress, hypoxia, and pneumothorax/pneumomediastinum may occur. Nocardia may produce a variety of pulmonary patterns, including miliary nodules.208,467208467. It is seen both in primary and post-primary tuberculosis and may be associated with tuberculous infection in numerous other tissues and organs. 39-2). The bacteria that cause tuberculosis are spread from one person to another through tiny droplets released into the air via coughs and sneezes.Once rare in developed countries, tuberculosis infections began increasing in 1985, partly because of the emergence of HIV, the virus that causes AIDS. Most infections show no symptoms, in which case it is known as latent tuberculosis. In the HIV-infected patients with advanced immunodeficiency, blood cultures are positive for M. tuberculosis in 20–40% of patients. Acute miliary tuberculosis presenting with shock and ARDS has a mortality which may approach 90%. Any of the fungal infections listed in Chart 17.1 may mimic the radiologic appearance of miliary tuberculosis, but this pattern is most commonly the result of histoplasmosis, coccidioidomycosis, or North American blastomycosis. Tuberculosis generally affects the lungs, but can also affect other parts of the body. Treatment of disseminated TB involves a combination of several medicines (usually 4). Treatment for latent TB infection and TB disease for the following populations have additional considerations. Some patients with histoplasmosis who develop this diffuse nodular pattern are later observed to develop diffuse, small, calcified nodules (answer to question 2 is e). Laboratory tests are often abnormal with anemia, thrombocytopenia, leukopenia or leukocytosis; elevated liver function tests and ESR, low albumin, signs of SIADH of sterile pyuria. CT or MRI scanning may show smaller nodules not apparent on X-ray. Constitutional symptoms such as fever, malaise and weight loss, predominate in the clinical presentation of miliary tuberculosis. Delay in diagnosis contributes to mortality. The role of rapid nucleic acid amplification tests for identification of M. tuberculosis in patients with miliary tuberculosis has not been defined, and neither of the two tests licensed by the U.S. Food and Drug Administration is approved for nonrespiratory specimens, although Xpert MTB/RIF is recommended for use with specimens from extrapulmonary sites by WHO.308 The reported data are difficult to interpret because, often, the results of specimens from different sites are combined, patients are selected by a variety of criteria, and test performance varies.309-311 In contrast, several studies have shown that Xpert MTB/RIF can provide rapid molecular diagnostic assessment when extrapulmonary tuberculosis is suspected. Xiang-Dong Mu, M.D., ... and broad-spectrum antibiotics were administered for 8 days as empirical treatment for the fever, without improvement. In more chronic cases, cachexia is prominent and localizing features may be few. 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