eMedicine Specialties > Infectious Diseases > Mycobacterial Infections

Miliary Tuberculosis

Author: Klaus-Dieter Lessnau, MD, FCCP, Clinical Assistant 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, RPA-C, MPH, Manager, Department of Global Epidemiology, Pfizer, Inc
Contributor Information and Disclosures

Updated: Oct 18, 2007

Introduction

Background

Miliary tuberculosis (TB) is the widespread dissemination of Mycobacterium tuberculosis from hematogenous spread. Classic miliary TB is defined as milletlike (mean 2 mm, range 1-5 mm) seeding of TB bacilli in the lung, as evidenced on chest radiography. This pattern is seen in 1-3% of all TB cases.

Miliary TB may occur in an individual organ (very rare, <5%), in several organs, or throughout the whole body (>90%), including the brain. The infection is characterized by a large amount of TB bacilli, although it may easily be missed and is fatal if untreated. Up to 25% of patients with miliary TB may have meningeal involvement. In addition, miliary TB may mimic many diseases. In some case series, up to 50% of cases are undiagnosed antemortem. Therefore, a high index of clinical suspicion is important to obtain an early diagnosis and to ensure improved clinical outcomes. Early empirical treatment for possible but not yet definitive miliary TB increases the likelihood of survival and should never be withheld while test results are pending.

On autopsy, multiple TB lesions are detected throughout the body in organs such as the lungs, liver, spleen, brain, and others.

Pathophysiology

Following exposure and inhalation of TB bacilli in the lung, a primary pulmonary complex is established and pulmonary lymphangitis and hilar lymphadenopathy develop. Mycobacteremia and hematogenous seeding occur after the primary infection. After initial inhalation of TB bacilli, miliary TB may occur as primary TB or may develop years after the initial infection. The disseminated nodules consist of central caseating necrosis and peripheral epithelioid and fibrous tissue. Radiographically, they are not calcified (as opposed to the initial Ghon focus, which often is visible on chest radiographs as a small calcified nodule).

Frequency

United States

Data from 1996 indicate that 257 (1.2%) of the 21,337 patients with TB were considered to have miliary TB. The CDC records epidemiologic data for TB.

International

Of all patients with TB, 1.5% are estimated to have miliary TB. The World Health Organization reports that 2-3 million patients die with and/or from all forms of TB each year.1

Mortality/Morbidity

  • Untreated, the mortality rate is assumed to be close to 100%. With early and appropriate treatment, the mortality rate is reduced to less than 10%. The earlier the diagnosis, the better the likelihood of a positive outcome. Early treatment for suspected TB has shown to improve outcome.
  • Most deaths occur within the first 2 weeks of admission to the hospital. This may be related to delayed onset of treatment.
  • Up to 50% of all cases of disseminated TB detected at autopsy were missed antemortem in reported case series.

Race

  • The incidence of miliary TB may be higher in African Americans in the United States because of socioeconomic risk factors. No genetic predisposition has been identified.

Sex

  • In the United States, men may have a higher incidence than women because of socioeconomic and medical risk factors.

Age

Miliary disease is more difficult to detect in patients who are very young or very old.

  • Children younger than 5 years who acquire miliary TB are more likely to develop life-threatening miliary and/or meningeal TB. The disease usually follows primary infection, with no or only a short latency period.
  • Adults older than 65 years have a higher risk of miliary TB. Clinically, it may be subacute or may masquerade as a malignancy. If undiagnosed, the disease is detected at autopsy.

Clinical

History

  • Patients may experience progressive symptoms over days to weeks or occasionally over several months. Symptoms include the following:
    • Weakness, fatigue (90%)
    • Weight loss (80%)
    • Headache (10%)

Physical

  • Signs include the following:
    • Subtle signs, such as low-grade fever (20%)
    • Fever (80%)
    • Cough (60%)
    • Generalized lymphadenopathy (40%)
    • Hepatomegaly (40%)
    • Splenomegaly (15%)
    • Pancreatitis (<5%)
    • Multiorgan dysfunction, adrenal insufficiency

Causes

  • Risk factors involve immunosuppression and include, but are not limited to, the following:
    • Cancer
    • Transplantation
    • HIV infection
    • Malnutrition
    • Diabetes
    • Silicosis
    • End-stage renal disease
    • Major surgical procedures - Occasionally may trigger dissemination

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. 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. Miliary tuberculosis: clinical manifestations, diagnosis and outcome in 38 adults. Respirology. 2001;6:217-224.

  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. 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].

  14. 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].

  15. 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].

  16. 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 Assistant 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: Nothing to disclose.

Coauthor(s)

Cynthia de Luise, RPA-C, MPH, Manager, Department of Global Epidemiology, Pfizer, Inc
Cynthia de Luise, RPA-C, MPH is a member of the following medical societies: American Academy of Physician Assistants and American Public Health Association
Disclosure: Nothing to disclose.

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: Nothing to disclose.

Managing Editor

Aaron Glatt, MD, Professor of Clinical Medicine, New York Medical College; 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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