Advertisement

Tuberculosis pp 273-300 | Cite as

Miliary/Disseminated Tuberculosis

  • M. Monir Madkour
Chapter

Abstract

Miliary/disseminated tuberculosis signifies the widespread occurrence of caseating visceral tuberculosis that occurs by hematogenous dissemination of the bacilli from an active caseous focus or foci located in the lung or extrapulmonary sites. Hematogenous dissemination of the bacilli may occur during the course of primary tuberculosis, immediately after the post-primary period, or at a time far remote from the post-primary period as late generalized tuberculosis (LGT) (Slavin et al. 1980). A wide spectrum of pathological features occurs as a result of hematogenous dissemination of the bacilli. This spectrum of pathology is determined by the size of the bacillary inoculum load, the virulence of the bacilli, and the status of the host immune response. It ranges from a rare but acute fulminating form due to the release of massive myriads of caseous and necrotic tubercles into the blood with a nonreactive and an anergic response, very low count of CD4+ T-cells with scanty or absent granuloma formation; that form of the disease is only diagnosed at autopsy. If, on the other hand, tuberculous bacteremia is slight with the formation of few tubercles, this discrete type of generalized dissemination is usually without immediate clinical significance, although these tubercles serve as ‘seed beds’ for the later development of organ tuberculosis or LGT (Slavin et al. 1980). Between these two pathological and clinical extremes lies a spectrum of pathology that varies in severity. The more common classic miliary tuberculosis resembles the fulminating form (Prout et al. 1980). Miliary tuberculosis is defined as a hematogenous dissemination of the bacilli resulting in widespread, active, visceral, caseous tubercle formations measuring 1–3 mm in diameter (the size of millet seeds) with radiologic or pathologic evidence of pulmonary micronodules (Sahn and Neff 1974; Slavin et al. 1980; Penner et al. 1995). Disseminated tuberculosis is defined as a hematogenous transmission of the bacilli with active caseous tubercle formation in two or more extrapulmonary sites and with no pulmonary miliary nodular shadowing on chest radiography (Penner et al. 1995; Sahn and Neff 1974). Proudfoot et al. (1969) described the fulminating dissemination form of tuberculosis in patients with other co-existing underlying disease that may lead to a clinical presentation with atypical features due to an impaired cellmediated immune response and the absence of miliary lung shadowing as ‘cryptic disseminated tuberculosis’, which is usually diagnosed at autopsy. Disseminated tuberculosis is a diagnostic challenge even in endemic areas when the attending clinician has a high index of suspicion. Chest radiography is usually the initial diagnostic investigation for miliary tuberculosis. The sensitivity of chest radiography was found to range from 59% to 69% in a study based on population and group control subject (Kwong et al. 1996). ARDS may occur as a complication of miliary tuberculosis, and chest radiography may be difficult to interpret since the miliary nodules are superimposed on a more diffuse ground (Armstrong et al. 1995). Fatal consequences if undiagnosed and untreated at an early stage may affect 21%–64% of patients with disseminated tuberculosis (Monie et al. 1983; Al-Jahdali et al. 2000; Prout et al. 1980; Bobrowitz 1982). Miliary/disseminated tuberculosis has increased in incidence in the USA,particularly among HIV co-infected patients (Rieder et al. 1991; Hill 1991; FitzGerald et al. 1991; Korzeniewska-Kosela et al. 1992).

Keywords

Chest Radiography Pulmonary Tuberculosis Adult Respiratory Distress Syndrome Situs Inversus Hematogenous Dissemination 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. Agarwal MK, Muthuswamy PP et al (1977) Respiratory failure in pulmonary tuberculosis. Chest 72:605–609PubMedCrossRefGoogle Scholar
  2. Al Bhlal LA (2001) Fine-needle aspiration cytology of postvaccinial disseminated bacillus Calmette-Guerin infection. Diagn Cytopathol 24:333–335PubMedCrossRefGoogle Scholar
  3. Al-Jahdali H, Al-Zahrani K et al (2000) Clinical aspects of miliary tuberculosis in Saudi adults. Int J Tuberc 4:252–255Google Scholar
  4. Armstrong P, Wilson AG, Dee P et al (1995) Imaging of disease of the chest, 2nd edn. Mosby Year Book, Chicago, p 183Google Scholar
  5. Ashburg DG, Bigelow DB et al (1967) Acute respiratory distress in adults. Lancet 2:319Google Scholar
  6. Auerbach O (1944) Acute generalized miliary tuberculosis. Am JPathol 20:121–136Google Scholar
  7. Auerbach O (1959) The natural history of the tuberculous pulmonary lesion. Med Clin North Am 43:239–251PubMedGoogle Scholar
  8. Bateman DE, Makepeace W et al (1980) Miliary tuberculosis in association with chronic cutaneous tuberculosis. Br J Dermatol 103:557–560PubMedCrossRefGoogle Scholar
  9. Berger HW, Samortin TG (1970) Miliary tuberculosis: diagnostic methods with emphasis on the chest roentgenogram. Chest 58:586–589PubMedCrossRefGoogle Scholar
  10. Bernard GR, Artigas A et al (1994) The American-European Consensus Conference on ARDS: definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 149:818–824PubMedCrossRefGoogle Scholar
  11. Biehl JP (1958) Miliary tuberculosis: a review of 68 adult patients admitted to a municipal general hospital. Am Rev Tuberc Pul Dis 77:605–622Google Scholar
  12. Bobrowitz ID (1982) Active tuberculosis undiagnosed until autopsy. Am J Med 72:650–658PubMedCrossRefGoogle Scholar
  13. Bone M, Stableforth D (1981) Miliary infection to Mycobacterium avium-intracellulare. Tubercle 62:211–213PubMedCrossRefGoogle Scholar
  14. Cassim KM, Gathiram V et al (1993) Pancytopenia associated with disseminated tuberculosis, reactive histiocytic haemophagocytic Syndrome and tuberculous hypersplenism. Tubercle Lung Dis 74:208–210CrossRefGoogle Scholar
  15. Chandra KS, Prasad AS et al (1988) Recurrent pneumothoraces in miliary tuberculosis. Trop Geogr Med 40:347–349PubMedGoogle Scholar
  16. Chapman CB, Whorton CM (1946) Acute generalized miliary tuberculosis in adults. A clinicopathological study based on 63 cases diagnosed at autopsy. N Engl J Med 235:239–248PubMedCrossRefGoogle Scholar
  17. Chugh IM, Agarwal AK (1997) Bilateral miliary pattern in sarcoidosis. Indian J Chest Dis Allied Sei 39:245–249Google Scholar
  18. Clarridge J et al (1993) Large-scale use of polymerase chain reaction for detection of Mycobacterium tuberculosis in a routine mycobacteriology laboratory. J Clin Microbiol 31: 2049–2056PubMedGoogle Scholar
  19. Crump JA (1998) Miliary tuberculosis with paradoxical expansion of intracranial tuberculomas complicating human immunodeficiency virus infection in a patient reeeiving highly active antiretroviral therapy. Clin Infect Dis 26: 1008–1009PubMedCrossRefGoogle Scholar
  20. Curull V, Morell F et al (1985) Dyspnea, fever and miliary pattern. Chest 88:285–286PubMedCrossRefGoogle Scholar
  21. Dahmash NS, Fayed DF et al (1995) Diagnostic challenge of tuberculosis of the elderly in hospital: experience at a university hospital in Saudi Arabia. J Infect 31:93–97PubMedCrossRefGoogle Scholar
  22. Dannenberg AM Jr (2001) Pathogenesis of pulmonary Mycobacterium bovis infection: basic principles established by the rabbit model. Tuberculosis 81:87–96PubMedCrossRefGoogle Scholar
  23. Dee P, Teja K et al (1980) Miliary tuberculosis resulting in adult respiratory distress Syndrome: a surviving case. Am J Roentgenol 134:569–572CrossRefGoogle Scholar
  24. De Hertogh Fierer E et al (1989) Hypersensitivity reaction to bacillus Calmette Guerin treated with plasmapheresis. Am J Med 86:343–344PubMedCrossRefGoogle Scholar
  25. Deresiewicz RL, Stone RM, Aster JC et al (1990) Fatal disseminated mycobacterial infection following intravesical bacillus Calmette Guerin. J Urol 144:1331–1334PubMedGoogle Scholar
  26. Dyer RA, Potgieter PD (1984) The adult respiratory distress Syndrome and bronchogenic pulmonary tuberculosis. Thorax 39:383–387PubMedCrossRefGoogle Scholar
  27. Dyer RA, Chappell WA et al (1985) Adult respiratory distress Syndrome associated with miliary tuberculosis. Crit Care Med 13:12–15PubMedCrossRefGoogle Scholar
  28. Ellner JJ (1997) Regulation of the human immune response during tuberculosis. J Lab Clin Med 130:469–475PubMedCrossRefGoogle Scholar
  29. Evans RH, Evans M et al (1998) Massive hepatosplenomegaly, jaundice and pancytopenia in miliary tuberculosis. J Infect 36:236–239PubMedCrossRefGoogle Scholar
  30. FitzGerald JM, Grzyrowski S et al (1991) The impact of immunodeficiency virus infection on tuberculosis and its control. Chest 100:191–200PubMedCrossRefGoogle Scholar
  31. Foster DR (1997) Miliary tuberculosis following intravesical BCG treatment. Br J Radiol 70:429–431PubMedGoogle Scholar
  32. Gelb AF, Leffler C et al (1973) Miliary tuberculosis. Am Rev Respir Dis 108:1327–1333PubMedGoogle Scholar
  33. Geppert EF, Leff A (1979) The pathogenesis of pulmonary and miliary tuberculosis. Arch Intern Med 139:1381–1383PubMedCrossRefGoogle Scholar
  34. Goldfine ID, Schachter H et al (1969) Consumption coagulopathy in miliary tuberculosis. Ann Intern Med 71:775–777PubMedCrossRefGoogle Scholar
  35. Graf-Deuel E, Knoblauch A (1994) Simultaneous bilateral spontaneous pneumothorax. Chest 105:1142–1146PubMedCrossRefGoogle Scholar
  36. Grieco MH, Chmel H (1974) Acute disseminated tuberculosis as a diagnostic problem. A clinical study based on 28 cases. Am Rev Respir Dis 109:554–560PubMedGoogle Scholar
  37. Gupta RC, Lavengood R et al (1988) Miliary tuberculosis due to intravesical bacillus Calmette-Guerin therapy. Chest 94: 1296–1298PubMedCrossRefGoogle Scholar
  38. Hill AR (1991) Disseminated tuberculosis in the acquired immunodeficiency Syndrome era. Am Rev Respir Dis 144: 1164–1170PubMedCrossRefGoogle Scholar
  39. Hong SH, Im JG et al (1998) High resolution CT findings of miliary tuberculosis. J Comput Assist Tomogr 22: 220–224PubMedCrossRefGoogle Scholar
  40. Iantorno R, Nicolai M et al (1998) Miliary tuberculosis of the lung in a patient treated with bacillus Calmette-Guerin for superficial bladder cancer. J Urol 159:1639–1640PubMedCrossRefGoogle Scholar
  41. Jacques J, Sloan JM (1970) The changing pattern of miliary tuberculosis. Thorax 25:237–240PubMedCrossRefGoogle Scholar
  42. Jasmer RM, McCowin MJ et al (1996) Miliary lung disease after intravesical bacillus Calmette-Guerin immunotherapy. Radiology 201:43–44PubMedGoogle Scholar
  43. Juul A (1977) Clinically undiagnosed active tuberculosis. Acta Med Scand 202:225–229PubMedCrossRefGoogle Scholar
  44. Kesten S, Title L et al (1990) Pulmonary disease following intravesical BCG treatment. Thorax 45:709–710PubMedCrossRefGoogle Scholar
  45. Korzeniewska-Kosela M, FitzGerald JM et al (1992) Spectrum of tuberculosis in HIV infected patients in British Columbia: a report of 40 cases. Can Med Assoc J 146: 1927–1934Google Scholar
  46. Köylü R, Tozkoparan E et al (1997) Unusual miliary tuberculosis presenting with generalized lymphadenopathy and abdominal involvement. Int J Tuberc Lung Dis 1:474–476PubMedGoogle Scholar
  47. Kwong JS, Carignan S et al (1996) Diagnostic accuracy of ehest radiography. Chest 110:339–342PubMedCrossRefGoogle Scholar
  48. Langdale LA, Meissner M et al (1992) Tuberculosis and the surgeon. Am J Surg 163:505–509PubMedCrossRefGoogle Scholar
  49. Long R, O’Connor R et al (1997) Disseminated tuberculosis with and without a miliary pattern on chest radiograph: a clinical-pathologic-radiologic correlation. Int J Tuberc Lung Dis 1:52–58PubMedGoogle Scholar
  50. Lotte A, Wasz-Hockert O et al (1984) BCG complications. Estimates of the risks among vaccinated subjeets and statistical analysis of their main characteristics. Adv Tuberc Res 21: 107–193PubMedGoogle Scholar
  51. Maartens G, Willcox PA et al (1990) Miliary tuberculosis: rapid diagnosis, haematologic abnormalities, and outcome in 109 treated adults. Am J Med 89:291–296PubMedCrossRefGoogle Scholar
  52. Massaro D, Katz S (1964) Rapid Clearing in hematogenous pulmonary tuberculosis. Arch Intern Med 113:573Google Scholar
  53. McClement JH, Renzetti AD, Carroll D et al (1951) Cardiopulmonary funetion in hematogenous pulmonary tuberculosis in patients reeeiving streptomyein therapy. Am Rev Tuberc 64:583PubMedGoogle Scholar
  54. McGuinness G, Naidich DP et al (1992) High resolution CT findings in miliary lung disease. J Comput Assist Tomogr 16:384–390PubMedCrossRefGoogle Scholar
  55. McParland C, Cotton DJ et al (1992) Miliary Mycobacterium bovis induced by intravesical bacilli Calmette-Guerin immunotherapy. Am Rev Respir Dis 146:1330–1333PubMedCrossRefGoogle Scholar
  56. Mert A, Bilir M et al (2001) Spontaneous pneumothorax: a rare complication of miliary tuberculosis. Ann Thorac Cardiovasc Surg 7:45–48PubMedGoogle Scholar
  57. Millar JW, Hörne NW (1979) Tuberculosis in immunosuppressed patients. Lancet 1:1176–1178PubMedCrossRefGoogle Scholar
  58. Miyake S, Yoshizawa Y et al (1997) Non-Hodgkin’s lymphoma with pulmonary infiltrates mimicking miliary tuberculosis. Intern Med 36:420–423PubMedCrossRefGoogle Scholar
  59. Mohan A, Sharma SK et al (1996) Acute respiratory distress Syndrome (ARDS) in miliary tuberculosis: a twelve year experience. Indian J Chest Dis Allied Sei 38:157–162Google Scholar
  60. Monie RDH, Hunter AM et al (1983) Retrospective survey of the management of miliary tuberculosis in South and West Wales, 1976–8. Thorax 38:369–372PubMedCrossRefGoogle Scholar
  61. Munt PW (1972) Miliary tuberculosis in the chemotherapy era: with a clinical review in 69 American patients. Medicine 51:139–155PubMedCrossRefGoogle Scholar
  62. Murray HW, Tuazon CU et al (1978) The adult respiratory distress Syndrome associated with miliary tuberculosis. Chest 73:37–43PubMedCrossRefGoogle Scholar
  63. Myers JA (1970) Miliary tuberculosis in the elderly. Br Med J 1:565PubMedCrossRefGoogle Scholar
  64. Nolte FS et al (1993) Direct detection of Mycobacterium tuberculosis in sputum by polymerase chain reaction and DNA hybridization. J Clin Microbiol 31:1777–1782PubMedGoogle Scholar
  65. Oh YU, Kim YH et al (1994) High-resolution CT appearance of miliary tuberculosis. J Comput Assist Tomogr 18:862–866PubMedCrossRefGoogle Scholar
  66. Optican RJ, Ost A et al (1992) High-resolution computed tomography in the diagnosis of miliary tuberculosis. Chest 102:941–943PubMedCrossRefGoogle Scholar
  67. Orihuela E, Herr HW, Pinsky CM et al (1987) Toxicity of intravesical BCG and its management in patients with superficial bladder tumors. Cancer 60:326–333PubMedCrossRefGoogle Scholar
  68. Ormerod LP, Horsfield N (1995) Miliary tuberculosis in a high prevalence area of the UK: Blackburn 1978–1993. Resp Med 89:555–557CrossRefGoogle Scholar
  69. Pagel W, Simmonds FAH et al (1964) Pulmonary tuberculosis, 4th edn. Oxford University Press, London.Google Scholar
  70. Palayew M, Briedis D et al (1993) Disseminated infection after intravesical BCG immunotherapy. Chest 104:307–309PubMedCrossRefGoogle Scholar
  71. Pasculle AW, Kapadia SB et al (1980) Tuberculous bacillemia, hyperpyrexia, and rapid death. Arch Intern Med 140:426–427PubMedCrossRefGoogle Scholar
  72. Penner C, Roberts D et al (1995) Tuberculosis as a primary cause of respiratory failure requiring mechanical Ventilation. Am J Respir Crit Care Med 151:867–872PubMedCrossRefGoogle Scholar
  73. Petty TL, Ashburg DG (1971) The adult respiratory distress Syndrome: clinical features, factors influencing prognosis and principles of management. Chest 60:233–239PubMedCrossRefGoogle Scholar
  74. Piqueras AR, Marruecos L et al (1987) Miliary tuberculosis and adult respiratory distress Syndrome. Intensive Care Med 13:175–182PubMedCrossRefGoogle Scholar
  75. Pitchenik AE, Fertel D, Bloch AB (1988) Mycobacterial disease: epidemiology, diagnosis, treatment,and prevention. Clin Chest Med 9:425–441PubMedGoogle Scholar
  76. Proudfoot AT,A sktan A, Douglas AC et al (1969) Miliary tuberculosis in adults. Br Med J 2:273–276PubMedCrossRefGoogle Scholar
  77. Prout S, Benatar SR et al (1980) Disseminated tuberculosis. S Afr Med J 58:835–842PubMedGoogle Scholar
  78. Rabe J, Neff KW et al (1999) Miliary tuberculosis after intravesical bacilli Calmette-Guerin immunotherapy for carcinoma of the bladder. Am J Roentgenol 172:748–750CrossRefGoogle Scholar
  79. Rawls WH, Lamm DL et al (1990) Fatal sepsis following intravesical bacillus Calmette Guerin administration for bladder cancer. J Urol 144:1328–1330PubMedGoogle Scholar
  80. Ray M, Kataria S et al (2002) Unusual presentation of disseminated tuberculosis. Indian Pediatr 39:88–91PubMedGoogle Scholar
  81. Rieder HL, Kelly GD, Bloch AB et al (1991) Tuberculosis diagnosed at death in the United States. Chest 100:678–681PubMedCrossRefGoogle Scholar
  82. Rosenberg MJ, Rumans LW (1978) Survival of a patient with pancytopenia and disseminated coagulation associated with miliary tuberculosis. Chest 73:536–539PubMedCrossRefGoogle Scholar
  83. Sahn SA, Neff TA (1974) Miliary tuberculosis. Am J Med 56: 495–505CrossRefGoogle Scholar
  84. Saye L (1936) Tuberculosis miliar cronica. Rev Med Barcelona 25:387–423Google Scholar
  85. Shafer RW, Kim DS et al (1991) Extrapulmonary tuberculosis in patients with human immunodeficiency virus infection. Medicine 70:384–397PubMedCrossRefGoogle Scholar
  86. Shalwar R et al (1993) Detection of Mycobacterium tuberculosis in clinical samples by amplification of DNA. J Clin Microbiol 29:712–717Google Scholar
  87. Sharma SK, Shamim SQ et al (1981) Disseminated tuberculosis presenting as massive hepatosplenomegaly and hepatic failure. Am J Gastroenterol 76:153–156PubMedGoogle Scholar
  88. Sharma SK, Pande JN et al (1988) Bronchoalveolar lavage (Bai) in miliary tuberculosis. Tubercle 69:175–178PubMedCrossRefGoogle Scholar
  89. Sharma SK, Pande JN et al (1992) Pulmonary function and immunologic abnormalities in miliary tuberculosis. Am Rev Respir Dis 145:1167–1171PubMedCrossRefGoogle Scholar
  90. Shibolet A, Dan M et al (1979) Recurrent miliary tuberculosis secondary to infected ventriculoatrial shunt. Chest 76:328–330PubMedCrossRefGoogle Scholar
  91. Slavin RE, Walsh TJ et al (1980) Late generalized tuberculosis: a clinical pathologic analysis and comparison of 100 cases in the preantibiotic and antibiotic eras. Medicine 59:352–366PubMedCrossRefGoogle Scholar
  92. So SY, Yu D (1981) The adult respiratory distress Syndrome associated with miliary tuberculosis. Tubercle 62:49–53PubMedCrossRefGoogle Scholar
  93. Soloway MS (1988) Intravesical therapy for bladder cancer. Urol Clin North Am 15:661–669PubMedGoogle Scholar
  94. Stallworth JR, Brasfield DM et al (1980) Congenital miliary tuberculosis proved by open lung biopsy specimen and successfully treated. Am J Dis Child 134:320–321PubMedGoogle Scholar
  95. Steiner P, Rao M et al (1976) Miliary tuberculosis in two infants after nursery exposure: epidemiologic, clinical, and laboratory Undings. Am Rev Respir Dis 113:267–271PubMedGoogle Scholar
  96. Stenius-Aarniala BS, Tukiainen P (1979) Miliary tuberculosis. Acta Med Scand 206:417–422PubMedCrossRefGoogle Scholar
  97. Sutton FD, Hudson LD et al (1974) Recognition and management of the adult respiratory distress Syndrome. Chest 66:34S–36SPubMedCrossRefGoogle Scholar
  98. Treip C, Meyers D (1959) Fatal tuberculosis in a general hospital. A diagnostic problem. Lancet 1:164–167PubMedCrossRefGoogle Scholar
  99. Vanham G, Toossi Z, Hirsch CS et al (1997) Examining a paradox in the pathogenesis of human pulmonary tuberculosis: immune activation and suppression/anergy. Tubercle Lung Dis 78:145–158CrossRefGoogle Scholar
  100. Vijayan VK (2000) Disseminated tuberculosis. J Indian Med Assoc 98:107–109PubMedGoogle Scholar
  101. Willcox PA, Potgieter PD et al (1986) Rapid diagnosis of sputum negative miliary tuberculosis using the flexible fibreoptic bronchoscope. Thorax 41:681–684PubMedCrossRefGoogle Scholar
  102. Williams MH, Yoo OH (1973) Pulmonary function in miliary tuberculosis. Am Rev Respir Dis 107:858Google Scholar
  103. Yu YL, Chow WH et al (1986) Cryptic miliary tuberculosis. Q J Med 59:421–428PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2004

Authors and Affiliations

  • M. Monir Madkour
    • 1
  1. 1.Department of MedicineRiyadh Armed Forces HospitalRiyadhSaudi Arabia

Personalised recommendations