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Miliary tuberculosis

Case contributed by Dr Frank Gaillard

Presentation:

Being treated for psoriatic arthritis with adalimumab. Presents with deranged liver function tests and fevers.

Patient Data:

Age: 40 years
Gender: Female

Chest x-ray

Modality: X-ray

PA and lateral chest x-rays demonstrate wide spread small (2-4mm) nodular opacities distributed throughout both lungs. 

CT chest and upper abdomen

Modality: CT

CT of the chest confirms the presence of innumerable small pulmonary nodules, which have a centrilobular predilection. Dependent changes are also present. The mediastinum is unremarkable. 

CT of the upper abdomen demonstrates splenomegaly with multiple hypo-attenuating nodules, best seen on the portal venous phase. 

This patient went on to have a bronchoscopy with bronchial washings obtained. 

MICROSCOPY: Auramine-Rhodamine Stain:  No Acid Fast Bacilli Detected. A negative acid-fast smear result does not exclude the presence of Mycobacterium species.

ANTIGEN TESTING: MPT64 Antigen:  M.tuberculosis Complex DETECTED

NUCLEIC ACID TESTING: DNA Amplification Assay for M.tuberculosis Complex: DETECTED

MYCOBACTERIUM CULTURE

  • MGIT bottle (9 days): POSITIVE
  • Mycobacterium tuberculosis: ISOLATED

SENSITIVITIES

  • Ethambutol: sensitive
  • Isoniazid: sensitive
  • Pyrazinamide: sensitive
  • Rifampicin: sensitive

Case Discussion:

Adalimumab (along with infliximab and etanercept) is a TNF inhibitor. As of 2008 adalimumab has been approved by the FDA for the treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn's disease, moderate to severe chronic psoriasis and juvenile idiopathic arthritis. 

Although most easily seen in the lungs, miliary TB is a systemic illness with solid organs also affected. In this case splenic and hepatic involvement is evident. 

This patient went on to receive appropriate systemic antibiotics. 

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