Miliary Tuberculosis

Jerald Pelayo and Kathleen Ruddiman

N Engl J Med 2020; 383:e78
DOI: 10.1056/NEJMicm2001934

A 56-year-old man presented to the emergency department with a 2-month history of fatigue, weight loss of 10 kg, night sweats, and fever. He had a cough producing sputum that was occasionally bloodtinged. He had immigrated to the United States from Haiti 10 years earlier. On examination, his temperature was 36.2°C. He was breathing comfortably but appeared cachectic. On auscultation, the volume of airflow was equal in both lungs without crackles or wheeze. Dilated funduscopy showed polymorphic yellow lesions with indiscret borders in the posterior poles of both eyes. Chest radiography revealed widely distributed nodules of uniform size throughout both lung fields, a finding that was consistent with miliary tuberculosis. The ocular findings were consistent with choroidal tubercles. A sputum sample was smear-positive for acid-fast bacilli. The patient began receiving combination therapy with rifampin, isoniazid, pyrazinamide, and ethambutol. After 1 week of therapy, a repeat sputum sample was smear-negative for acid-fast bacilli. Pan-sensitive Mycobacterium tuberculosis was cultured from the initial sputum sample after 6 weeks. After the initiation of treatment, the patient’s symptoms improved, and he completed 6 months of therapy.

一名56岁男性患者因乏力、体重下降（10公斤）、盗汗和发热2个月到急诊科就诊。患者咳嗽咯痰，偶尔为血痰。10年前患者从海地移民到美国。体格检查发现，患者体温36.2°C，呼吸平稳，但呈恶液质。听诊显示双肺气流对称，没有啰音或哮鸣音。散瞳后眼底镜检查发现双眼后极多形性黄色病变，边界不清。胸片显示双肺广泛分布的小结节，大小一致，符合粟粒性结核表现。眼科表现符合脉络膜结节表现。痰涂片找到抗酸杆菌。患者开始接受利福平、异烟肼、吡嗪酰胺和乙胺丁醇治疗。治疗1周后，复查痰涂片未找到抗酸杆菌。6周后，最初留取的痰培养分离到全敏感的结核分枝杆菌。治疗开始后，患者症状改善，最终疗程为6个月。