Miliary tuberculosis

Case contributed by Ashesh Ishwarlal Ranchod
Diagnosis almost certain


Known HIV-positive patient on antiretroviral therapy. Presents with ongoing cough, night sweats and malaise.

Patient Data

Age: 40 years
Gender: Male

There are innumerable, multifocal, bilateral and generalized miliary nodules scattered through the lung fields. There is a normal cardiothoracic ratio, no mediastinal or hilar nodes are suspected, no pulmonary cavities, no effusions and no large conglomerate masses or cavities. There are no calcified nodules and no calcified lymph nodes.

There is likely normal liver and spleen size based on the abdominal X-rays. The abdomen is otherwise normal.


The spleen is at the upper limit of normal at 11.9cm. There are multiple, small, hypoechoic nodules throughout the spleen.

There are multiple, solid, non-necrotic epigastric, porta hepatic and para-aortic lymph nodes. There are no ascites. The liver is of normal-size echogenicity with no intrahepatic nodules or masses (images not uploaded).

Ultrasound of the abdomen and pelvis is otherwise normal.

Case Discussion

Miliary opacities in the lungs have a wide differential diagnosis including infective, inflammatory, and metastatic etiology. Occupational lung disease also needs to be considered. This may entail an extensive clinical and imaging workup after which a diagnosis can be made. In this instance, miliary tuberculosis, abdominal tuberculous lymphadenitis and splenic tuberculosis are suspected. In an HIV setting, the differential diagnosis of splenic/hepatic hypoechoic micronodules includes idiopathic, pyogenic, tuberculosis, fungal infection, Kaposi's sarcoma and lymphoma.

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