A 50 Year Old Man Who Has Been Chronically Sick Presents With Weight Loss, Cough And Weakness

A 50 year old man who has been sick for the past 5 years with fever, cough and fatigue and has been taking incomplete treatments from different primary care physicians presents with a cough, fever, weight loss, night sweats, extreme body weakness and pain through out the body. He was taking some cough syrups recently with no improvement in his symptoms.
On Examination patient is a thin man with poor hygiene and signs of weight loss. He is anemic and has palpable lymph nodes in his neck and axilla. He is coughing most of the time during the examination. He has decreased breath sounds through out the lung filed and on abdominal examination the spleen is enlarged.

His Chest X ray is shown below:

Based on the above history and the X ray picture what is the most probable diagnosis?
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Miliary Tuberculosis.

Case Discussion:
Miliary Tuberculosis is an uncommon manifestation of pulmonary tuberculosis and it represents hematogenous dissemination of uncontrolled tuberculous infection.

It can be seen both in primary and post primary tuberculous infection and it carries a very poor prognosis. It may be associated with tuberculous infection in many other organs and tissues as well.

Pathophysiology: It is well understood that the bacteria spread from the pulmonary system to the lymphatic system and then eventually to the blood stream the exact mechanism by which this occurs is not known. It is beleived that the tuberculos infection in the lungs results in erosion of the epithelial layer of alveolar cells and the spread of infection into a pulmonary vein. Once the bacteria reach the left side of the heart and enter the systemic circulation , they may multiply and infect the extrapulmonary organs. The cell mediated immunity is activated and so the infected sites become surrounded by macrophages which form granuloma giving the typical appearnce of miliary tuberculosis.

Radiographic Appearance Of Miliary Tuberculosis:

The plain radio graph shows miliary deposits as 1-3 mm diameter nodules which are uniform in appearance, size and distribution.

Clinical features: Patients may present with:

• Weakness
• Weight loss
• Headache
• Low grade fever
• Cough
• Generalized lyphadenopathy.
• Splenomegaly
• Hepatomegaly
• Pancreatitis
• Multi organ dysfunction

Management: The treatment depends upon the site of infection and spread, but usually requires a prolonged care and treatment. 

The standard treatment prescribed by WHO is with isoniazid and rifampicin for 6 months along with ethambutol and pyrizinamide for first 2 months. If there is evidence of meningitis then the treatment is extended for 12 months. The Us guide lines recommend nine months treatment.