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Miliary TB
Dr. Mahesh Chaudhary
Phase: A (March 2014)
Radiology & Imaging, BSMMU
General Considerations
• Widespread hematogenous dissemination of Mycobacterium tuberculosis
• Nodules are the size of mil...
Risk Factors
• Age – Child & Elderly
• Immunosuppression
• Cancer
• Transplantation
• HIV
• Malnutrition
• Diabetes
• Sili...
Pathophysiology of Miliary TB
• Tuberculous infection in the lungs results in erosion of
the epithelial layer of alveolar ...
Clinical Findings
• Onset is insidious
• Patients may not be acutely ill
• Symptoms include
 Weakness and fatigue (90%)
...
Lab Studies for Miliary TB
• CBC - Leukopenia/leukocytosis
• ESR - elevated in approximately 50% of patients
• Lumbar punc...
Imaging Findings
• Takes weeks between the time of dissemination and the
radiographic appearance
• Up to 30-50% have a nor...
Chest X-Ray
• Typical appearance only in 50% of cases
• Bilateral pleural effusions indicate dissemination.
This may be a ...
Chest CT scanning
• Chest CT scanning has higher sensitivity and
specificity than chest radiography in displaying well-
de...
USG
• Ultrasonography may reveal
 Diffuse liver disease
 Hepatomegaly
 Splenomegaly
 Para-aortic lymph nodes
 Minimum...
Differential Diagnosis
Treatment
• Four-drug regimen to start
 Isoniazid
 Rifampin
 Pyrazinamide
 Ethambutol or streptomycin
• Treatment may ...
Complications
• Dissemination via bloodstream to
 Prostate
 Seminal vesicles
 Epididymis
 Fallopian tubes
 Endometriu...
Prognosis
• If not treated, almost 100% fatal
• With treatment, less than 10% mortality
• Early treatment for suspected TB...
References
• D. Sutton Text book of Radiology & Imaging 7th
Ed
• Haaga CT & MRI of Whole body 5th
Ed
• Davidson’s Internal...
Miliary Tuberculosis (dr. mahesh)
Miliary Tuberculosis (dr. mahesh)
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Miliary Tuberculosis (dr. mahesh)

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Miliary TB

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Miliary Tuberculosis (dr. mahesh)

  1. 1. Miliary TB Dr. Mahesh Chaudhary Phase: A (March 2014) Radiology & Imaging, BSMMU
  2. 2. General Considerations • Widespread hematogenous dissemination of Mycobacterium tuberculosis • Nodules are the size of millet seeds (1-4mm, mean 2mm) • Miliary TB represents only 1-3% of all cases of tuberculosis • Up to 50% of cases are undiagnosed ante mortem • Extreme of ages, Immuno-compromised are more susceptible • Under age 5, there is an increased risk of meningitis • Seen both in primary and post-primary tuberculosis • When treated, clearing is frequently rapid
  3. 3. Risk Factors • Age – Child & Elderly • Immunosuppression • Cancer • Transplantation • HIV • Malnutrition • Diabetes • Silicosis • End-stage renal disease
  4. 4. Pathophysiology of Miliary TB • Tuberculous infection in the lungs results in erosion of the epithelial layer of alveolar cells and the spread of infection into a pulmonary vein • Bacteria reach the left side of the heart and enter the systemic circulation, they may multiply and infect extra pulmonary organs • Once infected, the cell mediated immune response is activated. The infected sites become surrounded by macrophages which form granuloma, giving the typical appearance of miliary tuberculosis
  5. 5. Clinical Findings • Onset is insidious • Patients may not be acutely ill • Symptoms include  Weakness and fatigue (90%)  Fever and weight loss (80%)  Chills, night sweats are common  Cough, Hemoptysis  Anorexia • Hepatomegaly and lymphadenopathy are common
  6. 6. Lab Studies for Miliary TB • CBC - Leukopenia/leukocytosis • ESR - elevated in approximately 50% of patients • Lumbar puncture - strongly considered Lymphocytic predominance (70%) Elevated protein levels (90%) Low glucose levels (90%) Acid-fast bacilli (≥40%) • Cultures for mycobacteria • PCR
  7. 7. Imaging Findings • Takes weeks between the time of dissemination and the radiographic appearance • Up to 30-50% have a normal chest radiograph • When first visible, they measure about 1 mm in size; they can grow to 3-5mm if left untreated • Produces innumerable, non-calcified nodules • HRCT scans are more sensitive at demonstrating small nodules • Bilateral, diffuse, random distribution • May be associated with intra- and interlobular septal thickening
  8. 8. Chest X-Ray • Typical appearance only in 50% of cases • Bilateral pleural effusions indicate dissemination. This may be a useful clue. • Nodules characteristic of miliary TB may be better visualized on lateral chest radiography (especially in the retrocardiac space). • Nodules are the size of millet seeds (1-5mm, mean=2mm)
  9. 9. Chest CT scanning • Chest CT scanning has higher sensitivity and specificity than chest radiography in displaying well- defined randomly distributed nodules. • High-resolution CT scanning with 1-mm cuts may be even better. It is useful in the presence of suggestive and inconclusive chest radiography findings.
  10. 10. USG • Ultrasonography may reveal  Diffuse liver disease  Hepatomegaly  Splenomegaly  Para-aortic lymph nodes  Minimum pleural effusion
  11. 11. Differential Diagnosis
  12. 12. Treatment • Four-drug regimen to start  Isoniazid  Rifampin  Pyrazinamide  Ethambutol or streptomycin • Treatment may continue for 6-9 months • 9-12 months with meningeal involvement
  13. 13. Complications • Dissemination via bloodstream to  Prostate  Seminal vesicles  Epididymis  Fallopian tubes  Endometrium  Meninges  Lymph nodes  Liver  Spleen  Skeleton  Kidneys  Adrenals
  14. 14. Prognosis • If not treated, almost 100% fatal • With treatment, less than 10% mortality • Early treatment for suspected TB has been shown to improve outcome • The relapse rate is 0-4% with adequate therapy • Most relapses occur during the first 24 months after completion of therapy
  15. 15. References • D. Sutton Text book of Radiology & Imaging 7th Ed • Haaga CT & MRI of Whole body 5th Ed • Davidson’s Internal Medicine 22nd Ed • Medscape • Pubmed Journals • Radiopedia.org • LearningRadiology.com

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