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Clinical manifestations, diagnosis, and treatment of miliary tuberculosis

Author
John Bernardo, MD
Section Editor
C Fordham von Reyn, MD
Deputy Editor
Elinor L Baron, MD, DTMH

INTRODUCTION

Miliary tuberculosis (TB) refers to clinical disease resulting from hematogenous dissemination of Mycobacterium tuberculosis. The term "miliary" was coined in 1700 by John Jacobus Manget, who likened the appearance of the involved lung to millet seeds, with its surface covered with small, firm white nodules (picture 1). The term miliary TB was originally a pathologic and then a radiographic description; it is now used to denote all forms of progressive, widely disseminated hematogenous TB. The term also may be used more broadly (and incorrectly) by some to denote involvement at multiple sites, whether or not disease presents with the classic radiographic or pathologic nodular appearance characteristic of hematogenous spread. Miliary TB can arise as a result of progressive primary infection or via reactivation of a latent focus with subsequent spread via the bloodstream.

The clinical manifestations, diagnosis, treatment, and prevention of miliary TB will be reviewed here. The epidemiology and pathogenesis of miliary and extrapulmonary TB are discussed separately. (See "Epidemiology and pathology of miliary and extrapulmonary tuberculosis".)

CLINICAL MANIFESTATIONS

Clinical manifestations of miliary tuberculosis (TB) are most likely to be subacute or chronic; less commonly, acute presentations also occur. Patients with subacute or chronic disease may present with failure to thrive [1], fever of unknown origin [2,3], and/or dysfunction of one or more organ systems [4]. Night sweats are frequent; rigors are unusual [5,6]. In one series including 38 patients, the median duration of illness prior to clinical presentation was two months [2]. The most common extrapulmonary sites include the lymphatic system, bones and joints, liver, central nervous system (CNS), and adrenal glands.

Acute miliary TB may be fulminant, including multiorgan system failure [7], a syndrome of septic shock [8], and acute respiratory distress syndrome (ARDS) [9,10]. Miliary TB is a relatively rare cause of acute respiratory failure and ARDS [11-13]; one study in South Africa (where the prevalence of TB is very high) noted approximately 2 percent of cases of ARDS were associated with disseminated TB [14]. The diagnosis of TB is more likely to be delayed or missed in patients presenting with acute respiratory failure rather than more typical symptoms of pulmonary or pleural TB [15]. Patients who develop miliary TB during primary infection can present with relatively acute onset and rapid clinical course. (See "Clinical manifestations and complications of pulmonary tuberculosis".)

Symptoms and signs of miliary TB are described in the tables (table 1 and table 2). Much of the data on clinical features of miliary TB comes from large retrospective series (table 3) [1,2,16-19]. These studies include a relatively large number of patients though differ markedly by year, inclusion criteria, country, and type of medical center; therefore, direct comparisons are difficult.

                       

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