2.3 Disseminated or miliary tuberculosis

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    Miliary TB is a generalised massive infection characterised by hematogenous diffusion of M. tuberculosis throughout the body. It is a medical emergency.


    The disease may manifest as a miliary pattern, or very small nodulary elements ("millet seeds") in the lungs.

    The classic acute form is mostly found in children, young adults and HIV-infected persons. The presentation can be either abrupt or insidious, with progressive deterioration in the patient’s physical condition. The clinical picture is often completed within one to two weeks and is characterised by a profoundly altered physical condition, marked wasting, headache and constant high fever. Discrete dyspnoea and coughing suggest a pulmonary focus; however, lungs can often be clear on auscultation. A moderate hepatosplenomegaly may be found. Certain forms of miliary TB evolve in a subacute manner over several months.
    Given this non-specific clinical picture, typhoid fever and septicaemia should be considered in the differential diagnosis.


    Diagnosis of miliary TB is confirmed by CXR (Chapter 3).
    When feasible, fundoscopy may reveal choroidal tubercles.
    Sputum smear examination is usually negative. When there is no possibility of obtaining CXR, the lack of response to antibiotics is an argument in favour of miliary TB.
    The tuberculin skin test is more likely to be falsely negative than in any other form of TB.
    In children, the risk of meningitis (20-40%) [1] Citation 1. Sharma, S.K., A. Mohan, and A. Sharma. Miliary tuberculosis: A new look at an old foe. J Clin Tuberc Other Mycobact Dis, 2016. 3: p. 13-27.
    is high. Lumbar puncture should be performed if miliary TB is suspected.