Tuberculosis pp 273-300 | Cite as

Miliary/Disseminated Tuberculosis



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).


Chest Radiography Pulmonary Tuberculosis Adult Respiratory Distress Syndrome Situs Inversus Hematogenous Dissemination 
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© Springer-Verlag Berlin Heidelberg 2004

Authors and Affiliations

  1. 1.Department of MedicineRiyadh Armed Forces HospitalRiyadhSaudi Arabia

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