eMedicine Specialties > Infectious Diseases > Mycobacterial Infections

Miliary Tuberculosis: Follow-up

Author: Klaus-Dieter Lessnau, MD, FCCP, Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital
Coauthor(s): Cynthia de Luise, PhD, MPH, Director, Epidemiology, Pfizer, Inc
Contributor Information and Disclosures

Updated: Nov 16, 2009

Follow-up

Further Inpatient Care

  • If the infected patient lives in a home with immunocompromised persons (eg, with HIV infection) or with children younger than 5 years, or if the patient lives in a communal residence type of facility (eg, homeless shelter, senior citizen facility, jail, prison), keep him or her hospitalized until sputum stain results are negative and significant clinical improvement is shown.
  • Evaluate all close contacts who might have been infected prior to initiation of effective therapy for evidence of tuberculosis (TB).
  • Contagiousness is low because miliary TB spreads hematogenously, not via the endobronchial system.
  • Cavitary lesions are highly unlikely.

Further Outpatient Care

  • Patient may start and continue treatment in an outpatient setting if no children or immunocompromised persons are in the home or if the patient is not in a communal residence facility.

Inpatient & Outpatient Medications

  • Each patient should be offered directly observed therapy in the clinic, home, or workplace.

Transfer

  • The patient is usually removed from isolation when 3 consecutive sputum smear results are negative and clinical improvement is shown.
  • The patient must not be confined with immunosuppressed patients prior to the establishment of negative sputum cultures.
  • Place the patient in a negative pressure room or in adequate respiratory isolation.

Deterrence/Prevention

  • Patients who discontinue medication may be subject to public health laws. Patients may be remanded to custody and ordered to continue therapy if judged to be a public health hazard.
  • When ordered compliance is not successful, the health department may obtain an order of detention.

Complications

  • Paradoxical enlargement of the lymph nodes or intracerebral tuberculomas during adequate treatment may require steroids.
  • Hydrocephalus may require neurosurgical decompression.

Prognosis

  • The relapse rate is 0-4% with adequate therapy and directly observed therapy, although results from studies vary.
  • Most relapses occur during the first 24 months after completion of therapy.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Negative tuberculosis (TB) skin testing results do not exclude the possibility of TB.
  • Negative sputum smear results (even 3 negatives) do not exclude the possibility of TB.
  • Diagnostic testing for suspected miliary TB should be continued and may include blood cultures, CT scanning, transbronchial biopsies, and bone marrow biopsy.
  • Failure to involve a TB specialist may lead to acquired resistant TB.
  • The local health department must be involved.

Special Concerns

  • Miliary TB during pregnancy can be treated safely with RIE (ie, rifampin, INH, vitamin B-6 [25 mg/d], and EMB [15 mg/kg/d]).
  • Miliary TB in a newborn of a mother with TB is difficult to diagnose.
    • Placenta examination by the pathologist is imperative.
    • Three gastric aspirates of the newborn are helpful.
    • Tuberculin skin testing of the newborn during the first 6 months is rarely helpful because of the limited immune response of the newborn.
    • Lumbar puncture is indicated if the newborn does not thrive.
    • Bacille Calmette-Guérin vaccine clouds the interpretation of a positive tuberculin skin test result after age 6 months.
 


More on Miliary Tuberculosis

Overview: Miliary Tuberculosis
Differential Diagnoses & Workup: Miliary Tuberculosis
Treatment & Medication: Miliary Tuberculosis
Follow-up: Miliary Tuberculosis
References
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References

  1. [Guideline] American Thoracic Society, US Centers for Disease Control and Prevention. Diagnostic Standards and Classification of Tuberculosis in Adults and Children. This official statement of the American Thoracic Society and the Centers for Disease Control and Prevention was adopted by the ATS Board of Directors, July 1999. This stat. Am J Respir Crit Care Med. Apr 2000;161(4 Pt 1):1376-95. [Medline].

  2. Alsoub H, Al Alousi FS. Miliary tuberculosis in Qatar: a review of 32 adult cases. Ann Saudi Med. Jan-Mar 2001;21(1-2):16-20. [Medline].

  3. Biedrzycki OJ, Baithun SI. TB-related sudden death (TBRSD) due to myocarditis complicating miliary TB: a case report and review of the literature. Am J Forensic Med Pathol. Dec 2006;27(4):335-6. [Medline].

  4. Blumberg HM, Burman WJ, Chaisson RE, Daley CL, Etkind SC, Friedman LN, et al. American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: treatment of tuberculosis. Am J Respir Crit Care Med. Feb 15 2003;167(4):603-62. [Medline].

  5. Bourbonnais JM, Sirithanakul K, Guzman JA. Fulminant miliary tuberculosis with adult respiratory distress syndrome undiagnosed until autopsy: a report of 2 cases and review of the literature. J Intensive Care Med. Nov-Dec 2005;20(6):354-9. [Medline].

  6. Hussain SF, Irfan M, Abbasi M, Anwer SS, Davidson S, Haqqee R, et al. Clinical characteristics of 110 miliary tuberculosis patients from a low HIV prevalence country. Int J Tuberc Lung Dis. Apr 2004;8(4):493-9. [Medline].

  7. Joint Tuberculosis Committee of the British Thoracic Society. Chemotherapy and management of tuberculosis in the United Kingdom: recommendations 1998. Thorax. Jul 1998;53(7):536-48. [Medline].

  8. Kim JH, Langston AA, Gallis HA. Miliary tuberculosis: epidemiology, clinical manifestations, diagnosis, and outcome. Rev Infect Dis. Jul-Aug 1990;12(4):583-90. [Medline].

  9. Lillebaek T, Thomsen VO. A patient with suspected sarcoidosis died from miliary tuberculosis. Scand J Infect Dis. 2000;32(2):218-20. [Medline].

  10. Maartens G, Willcox PA, Benatar SR. Miliary tuberculosis: rapid diagnosis, hematologic abnormalities, and outcome in 109 treated adults. Am J Med. Sep 1990;89(3):291-6. [Medline].

  11. Mert A, Bilir M, Tabak F, Ozaras R, Ozturk R, Senturk H, et al. Miliary tuberculosis: clinical manifestations, diagnosis and outcome in 38 adults. Respirology. Sep 2001;6(3):217-24. [Medline].

  12. Munt PW. Miliary tuberculosis in the chemotherapy era: with a clinical review in 69 American adults. Medicine (Baltimore). Mar 1972;51(2):139-55. [Medline].

  13. Myers JN. Miliary, central nervous system, and genitourinary tuberculosis. Dis Mon. Jan 2007;53(1):22-31. [Medline].

  14. Regnier S, Ouagari Z, Perez ZL, Veziris N, Bricaire F, Caumes E. Cutaneous miliary resistant tuberculosis in a patient infected with human immunodeficiency virus: case report and literature review. Clin Exp Dermatol. Jul 29 2009;[Medline].

  15. Shafer RW, Kim DS, Weiss JP, Quale JM. Extrapulmonary tuberculosis in patients with human immunodeficiency virus infection. Medicine (Baltimore). Nov 1991;70(6):384-97. [Medline].

  16. Sharma SK, Mohan A, Sharma A, Mitra DK. Miliary tuberculosis: new insights into an old disease. Lancet Infect Dis. Jul 2005;5(7):415-30. [Medline].

  17. Slavin RE, Walsh TJ, Pollack AD. Late generalized tuberculosis: a clinical pathologic analysis and comparison of 100 cases in the preantibiotic and antibiotic eras. Medicine (Baltimore). Sep 1980;59(5):352-66. [Medline].

  18. Stas P, D'Hoore A, Van Assche G, Geboes K, Steenkiste E, Penninckx F, et al. Miliary tuberculosis following infliximab therapy for Crohn disease: A case report and review of the literature. Acta Gastroenterol Belg. Apr-Jun 2006;69(2):217-20. [Medline].

  19. Talavera W, Lessnau KD, Handwerger S. Extrapulmonary tuberculosis. In: Friedman LN, ed. Tuberculosis: Current Concepts and Treatment. CRC Press: Boca Raton, Fla; 1994.

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Further Reading

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Keywords

miliary tuberculosis, miliary TB, TB bacilli, disseminated tuberculosis, TB, mycobacteremia, cryptogenic tuberculosis, Mycobacterium tuberculosis, M tuberculosis, mycobacteremia

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Contributor Information and Disclosures

Author

Klaus-Dieter Lessnau, MD, FCCP, Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital
Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Artificial Internal Organs, American Thoracic Society, Physicians for Social Responsibility, and Society of Critical Care Medicine
Disclosure: sepracor Ownership interest None

Coauthor(s)

Cynthia de Luise, PhD, MPH, Director, Epidemiology, Pfizer, Inc
Cynthia de Luise, PhD, MPH is a member of the following medical societies: American Academy of Physician Assistants, American Public Health Association, and International Society for Pharmacoepidemiology
Disclosure: Pfizer Salary Employment

Medical Editor

Joseph Richard Masci, MD, Chief of Infectious Diseases, Associate Director, Associate Professor, Department of Internal Medicine, Division of Infectious Diseases, Elmhurst Hospital Center, Mount Sinai School of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Aaron Glatt, MD, Professor of Clinical Medicine, New York Medical College; President and CEO, Former Chief Medical Officer, Departments of Medicine and Infectious Diseases, New Island Hospital
Aaron Glatt, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Infectious Diseases Society of America, International AIDS Society, and Society for Healthcare Epidemiology of America
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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