1. Depart. Of Pulmonology R4 백승숙

2. Miliary tuberculosis
In 1700, John Jacob Manget
Latin word miliarius, meaning related to millet seed
Resemblance of gross pathological findings to that of innumerable
millet seeds in size and appearance
Haematogenous, generalised, disseminated tuberculosis
Lungs  distant blood-borne spread  extrapulmonary tuberculosis
Intense systemic dissemination from the rupture of a Mycobacterium
tuberculosis-laden focus into a vascular channel

4. Miliary tuberculosis accounts for about 1–2% of all cases of tuberculosis and about 8% of all forms of extrapulmonary tuberculosis in immunocompetent

5. Demographic shift
The HIV/AIDS pandemic and widespread use of immunosuppressive
The modulating effect of BCG vaccination
Increasing use of CT scans and invasive diagnostic methods
Presently two peaks
Adolescents and young adults
Later in life among elderly people

9. Gross examination
Organs with high blood flow
eg, the spleen, liver, lungs, bone marrow, kidneys, adrenals
Small, punctate, grey to reddish brown coloured, rounded lesions
of more or less uniform size are discernible various organs
In advanced HIV infection
Poor granuloma formation with minimal cellular reaction
Severe necrosis, and abundant acid-fast bacilli
Foci of acute tuberculosis pneumonia involve airspaces
rather than the interstitium

11. In adult
Protean and non-specific
Most often the involvement is asymptomatic
Fever, anorexia, weight loss, lassitude, and cough is frequent
Apyrexial presentation with progressive wasting (older people)
Tuberculosis meningitis has been described in 10–30%
In children
Peripheral lymphadenopathy and hepatosplenomegaly
>> Chills, night sweats, haemoptysis, productive cough
Tuberculosis meningitis has been described in 20–40%

12. (CD4+ cell counts >500 cells/L)
; Similar to that observed in immunocompetent individuals
(CD4+ cell counts <200 cells/L)
; Disseminated and miliary tuberculosis are seen more
(CD4+ cell counts <100 cells/L)
; Cutaneous involvement
Immune reconstitution disease (IRD)
Paradoxical worsening of lesions in patients with tuberculosis
HIV-negative individuals with tuberculosis (32–36%)
HIV/tuberculosis co-infection within days to weeks of the
initiation of highly active antiretroviral therapy (HAART)

13. Choroidal tubercles
Pathognomonic of miliary TB
Valuable clue to the diagnosis

14.  Not useful as a diagnostic test in miliary tuberculosis
A higher proportion of tuberculin anergy
Cross reactivity with environmental mycobacteria
Tuberculin positivity due to BCG vacination
Typical of interstitial lung disease
Impairment of diffusion ; most frequent and severe abnormality
Mild reduction in flow rates ; peripheral airways involvement
Arterial hypoxaemia, hypocapnia (acute stage)

15. Newer in-vitro T-cell based interferon assays
Early Secretory Antigenic Target 6, Culture Filtrate Protein 10
Major targets of the T-cell response to M. tuberculosis
Commercially available in the ELISA and ELISPOT formats
Less affected by malnutrition, HIV infection, and BCG vaccination
 Useful in detecting latent tuberculosis infection, especially in
children with suspected tuberculosis in developing countries

17. Classic miliary pattern even when the chest radiograph looks apparently normal
Contrast-enhanced CT scan
; Better for detecting intrathoracic lymphadenopathy, calcification,
and pleural lesions

18. Figure 2. Thin-section CT scan obtained in a 29-year-old man with AML
Eisenhuber E Radiology 2002;222:
Figure 2. Thin-section CT scan obtained in a 29-year-old man with AML

19. Useful in the detection of associated lesions such as loculated
ascites, focal hepatic and splenic lesions, and cold abscess
Useful tool to assess the activity of various infectious lesions
including pulmonary tuberculosis

20. Wherever possible, efforts should be directed at procuring
tissue/fluid for mycobacterial culture and sensitivity testing
Criteria
Clinical presentation consistent with a diagnosis of tuberculosis
and responding to antituberculosis treatment
eg, pyrexia with evening rise of temperature, night sweats,
anorexia, and weight loss of greater than 6 weeks in duration
Typical miliary pattern on chest radiograph
And/or bilateral, diffuse reticulonodular lung lesions on a background
of miliary shadows either on chest radiograph or HRCT scan
Microbiological and/or histopathological evidence of tuberculosis

21. that there is no consensus regarding the optimum duration of treatment
Critical evaluation of published clinical series on miliary tuberculosis reveals
that there is no consensus regarding the optimum duration of treatment

22. * BTS guidelines - All patients with miliary tuberculosis undergo
In the absence of associated meningeal involvement
ATS, CDC, IDSA, BTS guidelines
6 months of treatment
- 2-month intensive phase with isoniazid, rifampicin, pyrazinamide,
and ethambutol or streptomycin
- 4-month continuation phase with isoniazid and rifampicin
In the presence of associated tuberculosis meningitis
At least 12 months of treatment
* BTS guidelines - All patients with miliary tuberculosis undergo
a lumbar puncture

23. No study has specifically evaluated the role of adjunct
corticosteroid treatment in patients with miliary tuberculosis
Absolute indication
Associated adrenal insufficiency
Adjunctive corticosteroid treatment
Miliary tuberculosis with
- tuberculosis meningitis, large pericardial or pleural effusion,
- dyspnoea and/or disabling chest pain, IRD, ARDS,
- immune complex nephritis, and histiocyticphagocytosis syndrome

25. At times bilateral, may be the presenting feature or may develop while the patient is receiving treatment
Most dreaded complications of miliary tuberculosis and is usually seen at the time of initial presentation
May develop at any time during the course of disease
Renal failure may occur due to direct renal parenchymal involvement
Can develop as a manifestation of IRD in HIV-infected patients

26. A unique form of hepatitis where widespread liver cell necrosis
; extrapulmonary focus has discharged into the portal circulation
 hepatic miliary tuberculosis
Drug-induced hepatitis
; standard guidelines should be followed in its management
Life-threatening complications
eg, myocarditis, congestive heart failure, infective endocarditis, pericarditis,
intracardiac mass, mycotic aneurysm, sudden cardiac death

28. The mortality related to miliary tuberculosis
15–20% in children
25–30% in adults
Delay in the diagnosis or commencement of treatment
; important cause of high mortality

29. BCG vaccination
Effective in reducing the incidence of miliary tuberculosis
Not effective in individuals who are already infected
Should not be administered to immunosuppressed hosts
Targeted tuberculin testing
Treatment of latent tuberculosis infection
Effort to develop a more effective vaccine

30. The national tuberculosis control programmes
The reasons for the severely cmpromised local T-cell response
The new interferon assays in the diagnosis of miliary tuberculosis
The proposed diagnostic criteria are strictly adhered to
The cause of death in patients with miliary tuberculosis
The optimum regimen and duration of treatment
The role of adjunctive corticosteroid therapy