Miliary TB

History 57 y/o Russian male with history of fever and elevated LFTs after having sinus surgery for recurrent polyps 6 months ago Extensive work up for source of fever including bone marrow biopsy, negative for infectious process

History Initially diagnosed with Wegener’s granulomatosis at OSH and placed on prednisone with temporal resolution of symptoms and normalization of LFTs While on prednisone had recurrence of fever and was admitted to The University of Miami Hospital for further work-up

Initial Liver Biopsy (OSH) Compatible with granulomatous hepatitis Fungal, bacterial and AFB stains and cultures were negative

Laboratory Testing Multiple negative blood cultures CMV, HCV, EBV, HSV, HBV PCR negative Aspergillus, endemic fungal serologies, Bartonella serology, Cryptococcal antigen, Histoplasma antigen negative Myeloperoxidase and proteinase antibodies negative

Laboratory Testing ANCA negative Alk Phos 192 ANA negative Alb 1.8 AST/LT 101/70 TB 0.6 Cr 1.1 IgG 2710 Iron 13 Ferritin 2264 Wbc 12.6 Plat 808 Hb/Hct 8.8/26 ESR 144

Initial Imaging Abdominal U/S: hepato-splenomegaly Abdominal MRI: numerous nodular foci throughout the liver CT chest: diffuse infiltrating process involving the liver and linear opacification RLL

Diagnosis

Laparoscopic Liver Biopsy

Laparoscopic Liver Biopsy

Laparoscopic Liver Biopsy

Laparoscopic Liver Biopsy Extensive necrotizing granulomatous inflammation Bacterial, fungal, and AFB stains were again negative

Diagnosis Liver specimen AFB cultures positive for MTB Currently on 4 drug anti-tuberculosis therapy Recent admission to UMH for adrenal insufficiency caused by abrupt discontinuation of prednisone