Miliary tuberculosis

Alternative names

Miliary tuberculosis; Tuberculosis - disseminated; Extrapulmonary tuberculosis

Definition

Tuberculosis (TB) is a contagious bacterial infection caused by the bacterium Mycobacterium

tuberculosis. It is "disseminated" if it has spread from the lungs to other organs of the body by the
blood or lymph system. See also tuberculosis - pulmonary.

Causes, incidence, and risk factors

Infection can develop after inhaling droplets sprayed into the air from a cough or sneeze by
someone infected with Mycobacterium tuberculosis. The disease is characterized by the
development of granulomas (granular tumors) in the infected tissues.

The usual site of the disease is the lungs, but other organs may be involved. The primary
infection usually has no symptoms. In the U.S., 95% of individuals the primary tuberculous
lesions will heal and there will be no further evidence of disease. Disseminated disease develops
in the minority of infected individuals whose immune systems do not successfully heal the primary
infection.

The disease may occur within weeks after the primary infection, or may lie dormant for years
before causing illness. Infants, the elderly, and those infected with HIV are at higher risk for rapid
progression to disease, because of their weaker immune systems.

In disseminated disease, organs and tissues affected can include: the lining of the heart
(pericardium), lining of the abdominal cavity (peritoneum), larynx (voice box), bronchus, cervical
lymph nodes, bones and joints, organs of the male or female urinary and reproductive
(genitourinary) system, eye, stomach, small bowel, lining of the brain and spinal cord (meninges),
and skin.

The risk of contracting TB increases with the frequency of contact with people who have the
disease, in crowded or unsanitary living conditions, and with poor nutrition.

An increased incidence of TB has been seen recently in the U.S. Factors that may be causing
this increase is tuberculous infection in people with AIDS and HIV infection, and increasing
numbers of homeless people. Another matter of concern is the development of drug-resistant
strains of TB.

Incomplete treatment of TB infections (such as not taking medications for the prescribed length of
time) can contribute to the proliferation of drug-resistant strains of bacteria.

About half of AIDS patients with a CD4 count less than 200 who develop TB will have
disseminated disease (not localized disease, as in pulmonary tuberculosis).
Symptoms

• sweating
• fatigue
• general discomfort, uneasiness, or ill feeling (malaise)
• weight loss
• cough
• shortness of breath
• fever

Additional symptoms that may be associated with this disease:

• paleness
• joint pain
• chills
• swollen glands
• abdominal swelling

Note: The symptoms will depend upon the affected body organ.

Signs and tests

Enlarged lymph nodes, enlarged liver, and enlarged spleen are revealed with physical exam.

Tests:

• chest x-ray
• sputum cultures
• tuberculin skin test
• bronchoscopy for biopsy or culture
• open lung biopsy
• pleural biopsy
• biopsies and cultures of affected organs or tissues
• retinal lesions revealed with fundoscopy

This disease may also alter the results of the following tests:

• peripheral smear
• serum calcium (may be elevated)
• mycobacterial culture of bone marrow

Treatment

The goal of treatment is to cure the infection with antitubercular drugs. These drugs include:
pyrazinamide, isoniazid (INH), rifampin, ethambutol, ethionamide, para-aminosalicylic acid (PAS),
amikacin, and streptomycin. Daily oral doses are continued for 1 year or longer.

For atypical tuberculosis infections, or drug-resistant strains, other drugs may be indicated to treat
the infection. A minimum of three drugs are started for treatment.
Hospitalization may be necessary to prevent the spread of the disease to others until the
infectious period is over, usually 2-4 weeks after the start of therapy. Normal activity can be
continued after the infectious period.

Expectations (prognosis)

Most disseminated forms of TB respond well to treatment.

Complications

All medications used to treat TB have some toxicity. Rifampin, pyrazinamide, and isoniazid
may cause a non-infectious liver inflammation. Rifampin may also cause an orange or brown
coloration of tears and urine, and can stain contact lenses and undergarments. Ethambutol may
reduce visual acuity or cause color blindness.

Other complications include:

• drug resistance
• relapse of the disease
• tuberculous meningitis
• respiratory failure
• adult respiratory distress syndrome (ARDS)

Calling your health care provider

Call your health care provider if known or suspected exposure to TB has occurred. All forms of TB
require prompt treatment.

Prevention

Vaccination BCG for tuberculin-negative persons exposed to persons with untreated TB is given
in some situations, but its effectiveness is under dispute. It is rarely used in the U.S. but is often
used abroad, in countries with higher rates of tuberculosis.

— MAHMUD CD9