One month of weight loss and cough with blood-tinged sputum.

PATIENT PRESENTATION

A previously healthy 49‐year‐old male presented to the emergency department (ED) for evaluation of multiple symptoms progressively worsening over 4–6 weeks. Symptoms included subjective fever, night sweats, pleuritic chest pain, productive cough with blood‐tinged sputum, and an unintentional weight loss of approximately 20 pounds. He was febrile upon arrival but otherwise had normal vital signs. He underwent computed tomography of the chest without contrast (Figure 1).

FIGURE 1

Computed tomography of the chest (axial) showing numerous miliary lesions within the lung parenchyma

DIAGNOSIS

Pulmonary tuberculosis

This patient was ultimately admitted to the hospital from the ED. Sputum cultures were obtained and were positive for acid‐fast bacilli on 3 separate cultures. He was started on rifampin, isoniazid, pyrazinamide, and ethambutol. Hospital infection control and the local health department were notified.

Miliary tuberculosis is an infection of Mycobacterium tuberculosis with lymphohematogenous dissemination, causing the “miliary” appearance. The term “miliary” describes the appearance of the disease being similar to that of millet seeds. Patient presentation is often non‐specific with constitutional symptoms. Treatment is often a 6‐month course: initially 2 months of rifampin, isoniazid, pyrazinamide and ethambutol followed by 4 months of rifampin and isoniazid. Miliary tuberculosis has a higher mortality rate compared to other forms of tuberculosis, often because of delays in diagnosis.