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Purpose: Miliary pulmonary tuberculosis (TB) among pregnant women after in vitro fertilization embryo transfer (IVF-ET) causes poor outcomes but is rarely reported. This study analyzed the clinical characteristics and risk factors of these patients to provide hints for further studies. Method: The demographic characteristics, clinical manifestations, radiologic features, treatment, and outcomes of six patients diagnosed from May 2012 to August 2021 in Xiangya Hospital and 69 patients that were reported in English or Chinese literature from January 1980 to August 2021 were retrospectively analyzed. Continuous variables were compared between groups by t-test or Mann-Whitney U test, and categorical variables were compared between groups by chi-square test or Fisher exact test. Univariate and multiple logistic regression analyses were used to determine the predictors of respiratory failure. Results: A total of 75 patients were included. The average age of patients was about 30 years. All patients had tubal obstruction; 5 of them were diagnosed with pelvic TB before. Thirteen cases had a history of pulmonary or extrapulmonary TB, six out of them without any antituberculosis treatment history. All patients were in their first or second trimester during the onset of symptoms. The average interval between onset of symptoms and radiologic examination was about 21 days. The most common abnormalities on chest computed tomography scan were multiple nodules, pulmonary infiltrate, and consolidation. Merely 10 patients obtained bacteriological diagnosis by Mycobacterium tuberculosis culture or polymerase chain reaction test. The other patients were clinically diagnosed. All the patients received antituberculosis treatment. Although 44% of patients had fatal complications, all cases were cured or improved after antituberculosis treatment. Unfortunately, only eight fetuses survived (10.6%). The most frequent and severe complication was type I respiratory failure (20%). Patients with expectoration, dyspnea, coarse breath sounds, ground-glass opacity, and pulmonary infiltrate or consolidation were more likely to have respiratory failure (P < 0.05). Ground-glass opacity (OR = 48.545, 95% CI = 2.366-995.974, P = 0.012) and pulmonary infiltrate or consolidation (OR = 19.943, 95% CI = 2.159-184.213, P = 0.008) were independent predictors for respiratory failure. Conclusion: Tube infertility with underscreened or untreated TB is a risk factor for miliary TB during pregnancy after IVF-ET. Ground-glass opacity and pulmonary infiltrate or consolidation are predictors of respiratory failure. We demonstrate risk factors for incidence and complications to supply clues for future intervention and improve patient prognosis.

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An association of autoimmune hemolytic anemia with disseminated tuberculosis is an exceedingly rare entity. We describe herein a case of cold hemolytic autoimmune anemia associated with miliary tuberculosis resolved with blood transfusions, therapeutic plasma exchange, and antituberculous agents. We discuss the advantages of therapeutic plasma exchange at an early stage in the management of this condition.

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Acute respiratory distress syndrome (ARDS) represents a rare complication of miliary tuberculosis (TB) in the adult setting, and it is even less common in the pediatric population. The presence of comorbidities and the possibility of a delayed diagnosis may further impair the clinical prognosis of critically ill patients with disseminated TB and acute respiratory failure. In this report, we present a case series of five pediatric patients with miliary TB and ARDS, where rescue and multimodal respiratory support strategies have been applied with a favorable outcome in more than half of them. The burden of miliary TB over time on a general pediatric intensive care unit-including two ARDS patients-is also illustrated.

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Tuberculosis (TB) affecting a prosthetic knee is an unusual and diagnostically challenging presentation of this disease. This study reported a case of an 80-year-old man with a left total knee arthroplasty (TKA) performed eight years before his presentation. He presented with left knee swelling and pain for one month. Knee X-rays showed a normal joint space with no loosening of his prosthesis. His chest X-ray showed miliary disease, and microbiological studies of his sputum and synovial fluid aspirate grew Mycobacteria tuberculosis complex. He was successfully medically treated with anti-tuberculous therapy alone for one year. His knee hardware was retained, and he did not require debridement, resection, or revision. It is believed that this is the first reported case of miliary TB with delayed-onset TKA prosthetic joint infection (PJI) in which the prosthesis was successfully retained. Thirty-eight published TB TKA PJI cases in medical literature were also reviewed.

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OBJECTIVE: To analyse the clinical characteristics of miliary tuberculosis (TB) in pregnant women after in vitro fertilisation and embryo transfer (IVF-ET). METHODS: Six pregnant women with miliary TB after IVF-ET between October 2010 and July 2015 were retrospectively analysed. RESULTS: The patients were aged between 29 and 39 years. Fever, cough and dyspnoea were the main symptoms, and started during the first and second trimesters of pregnancy. Erythrocyte sedimentation rate and C-reactive protein were increased. White blood cell count was normal or slightly increased. Tuberculin purified protein derivative and acid-fast smear of sputum tests were negative. T-SPOT®.TB was performed in two cases and the results were positive. Chest computed tomography showed typical miliary nodules. One patient had tuberculous meningitis. Although all patients were cured, the foetuses died. CONCLUSIONS: The principal symptoms of miliary TB in pregnant women after IVF-ET were fever and dyspnoea. Physicians should consider the occurrence of miliary TB, particularly in the case of fever of long duration, respiratory symptoms and no response to antibiotic treatment.

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This article reports the fulminant course of a pneumogenic sepsis with severe ARDS (acute respiratory failure) in a 36-year-old female Indian patient, who died within 14 h after admission to the intensive care unit due to a multiorgan failure. During treatment the diagnosis of a miliary tuberculosis was suspected but was only confirmed by the autopsy. Due to high hygiene standards, miliary tuberculosis as the cause of septic shock is rare in Europe. Only 1-2% of the patients with pulmonary miliary tuberculosis develop an ARDS with a mortality of 60-90%. Based on this case the diagnostics as well as treatment of the patient are described. Furthermore, the management of an open tuberculosis on an intensive care unit is explained.

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BACKGROUND: Untreated, miliary tuberculosis (TB) has a mortality approaching 100%. As it is uncommon there is little specific data to guide its management. We report detailed data from a UK cohort of patients with miliary tuberculosis and the associations and predictive ability of admission blood tests with clinical outcomes. METHODS: Routinely collected demographic, clinical, blood, imaging, histopathological and microbiological data were assessed for all patients with miliary TB identified from the London TB register from 2008 to 2012 from Northwest London Hospitals NHS Trust. Multivariable logistic regression was used to assess factors independently associated with the need for critical care intervention. Receiver operator characteristics (ROC) were calculated to assess the discriminatory ability of admission blood tests to predict clinical outcomes. RESULTS: Fifty-two patients were identified with miliary tuberculosis, of whom 29% had confirmed central nervous system (CNS) involvement. Magnetic resonance imaging (MRI) was more sensitive than computed tomography (CT) or lumbar puncture for detecting CNS disease. Severe complications were frequent, with 15% requiring critical care intervention with mechanical ventilation. This was independently associated with admission hyponatraemia and elevated alanine aminotransferase (ALT). Having an admission sodium ≥125 mmol/L and an ALT <180 IU/L had 82% sensitivity and 100% specificity for predicting a favourable outcome with an area under the ROC curve (AUC) of 0.91. Despite the frequency of severe complications, one-year mortality was low at 2%. CONCLUSIONS: Although severe complications of miliary tuberculosis were frequent, mortality was low with timely access to critical care intervention, anti-tuberculous therapy and possibly corticosteroid use. Clinical outcomes could accurately be predicted using routinely collected biochemistry data.

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A 23-year-old woman had dry cough, fever and chest tightness for 1 months. Through thoracic CT scan and serological examination, the patient was clinically diagnosed as disseminated tuberculosis. she was given anti-tuberculosis therapy combined with autologous cytokine-induced killer (CIK) immunotherapy. Through the close follow-ups we found that after immunotherapy Her condition would have a swift improvement and she do not appear liver damage after a large doses of antibiotic therapy. In conclusion, adjuvant autologous CIK immunotherapy is an effective approach for disseminated tuberculosis.

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The management and therapy of miliary tuberculosis: Nobuharu OHSHIMA (Asthma and Allergy Center, National Hospital Organization Tokyo National Hospital). Treatment and management of severe pulmonary tuberculosis: Yuta HAYASHI, Kenji OGAWA (Department of Respiratory Medicine, National Hospital Organization Higashi Nagoya National Hospital). Death of a young (non-elderly) patient may become a large psychological burden not only for patient's family but also for medical staff. We analyzed non-elderly cases with severe pulmonary tuberculosis by comparing 13 patients who died of tuberculosis in the hospital (death group) and 31 patients who survived and were discharged from hospital (survivor group). The mean age was older and there were more patients who were out of employment in the death group compared to the survivor group. Among the factors related to the general condition evaluated on the admission, disturbance of consciousness, respiratory insufficiency, impairment in the ADL, poor dietary intake, and decubitus ulcer were more observed in the death group. Chest X-ray finding was not a predictive factor of poor prognosis. Among the laboratory findings, the numbers of peripheral blood lymphocytes, red blood cells, and thrombocytes significantly decreased in the death group. Serum level of total cholesterol, cholinesterase, and albumin were also significantly lower in the death group, indicating that malnutrition was related to the death of severe tuberculosis. Further studies are needed to establish the optimal nutritional management and evaluate the effectiveness of adjunctive use of steroid for severe tuberculosis patients. Invasive fungal infection complicated with pulmonary tuberculosis: Akira WATANABE, Katsuhiko KAMEI (Division of Clinical Research, Medical Mycology Research Center, Chiba University). Among the invasive mycoses, chronic pulmonary aspergillosis (CPA) is the most frequent disease as a sequel to pulmonary tuberculosis. However, identifying CPA early in patient with persistent pulmonary shadows from pulmonary tuberculosis is difficult. Serum microbiological tests such as Aspergillus precipitans (principally for Aspergillus IgG antibodies) are useful but sensitivity and specificity of this test are not high. Even treated, CPA has a case mortality rate of 50% over a span of 5 years. Morbidity is marked by both systemic and respiratory symptom and hemoptysis. Loss of lung function and life-threatening hemoptysis are common. As invasive pulmonary aspergillosis, early diagnosis and treatment of CPA might improve the outcome. Regarding the treatment, concomitant use of some anti-tubercular agents and antifungals is contradicted. Treatment and management for pulmonary tuberculosis complicated with COPD and interstitial pneumonia: Shinji TAMAKI, Takashi KUGE, Midori TAMURA, Sayuri TANAKA, Eiko YOSHINO, Mouka TAMURA (National Hospital Organization Nara Medical Center), Hiroshi KIMURA (Second Department of Internal Medicine and Respiratory Medicine, Nara Medical University) Recently, patients of pulmonary tuberculosis have many complications especially in the elderly population. It is recognized that patients with COPD and interstitial pneumonia (IP) have an increased risk for developing active tuberculosis. The aim of this report is to describe the clinical findings of pulmonary tuberculosis complicated with COPD and IP. We reviewed 327 patients who were diagnosed as pulmonary tuberculosis. Twenty-six cases were complicated with COPD. All patients were male, and had smoking history. Cavitary lesions were observed only in 5 cases. Acute exacerbation of COPD occurred in one fatal case. Ten cases were complicated with IP. Cavitary lesions were observed in 3 cases. Acute exacerbation of IP were observed in 7 cases, and 4 patients died during the anti-tuberculosis treatment. Careful evaluation and treatment are necessary for tuberculosis patients complicated with COPD and IP.

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Se describe el caso clínico de un anciano, en estado senil y desnutrido, quien presentaba síndrome febril prolongado, por lo que fue ingresado en el Hospital Clinicoquirúrgico Docente Dr Ambrosio Grillo Portuondo de Santiago de Cuba, pero al efectuar los exámenes complementarios no se obtuvo un diagnóstico definitivo. Posteriormente tuvo descompensación cardiovascular y fue trasladado a la Unidad de Terapia Intensiva, donde se le realizó urgentemente una radiografía de tórax, la cual mostró lesiones características de tuberculosis milliar. En consecuencia, se interconsultó con especialistas de neumología y se decidió iniciar el tratamiento con drogas antituberculosas; sin embargo, el paciente falleció un día después de comenzada la terapia. La necropsia mostró una granulomatosis crónica inespecífica, cuyo resultado solo se confirmó 2 meses más tarde, cuando el cultivo de las secreciones bronquiales fue positivo (codificación 7) de Mycobacterium tuberculosis(AU)

A case report of an elderly man in senile and malnourished state was described, who had prolonged febrile syndrome and was admitted to Dr Ambrosio Grillo Portuondo Clinical and Surgical Teaching Hospital of Santiago de Cuba, but a definitive diagnosis could not be obtained with complementary tests. Later he had cardiovascular decompensation and was transferred to the Intensive Care Unit, where he underwent an emergent chest radiograph, which showed characteristic lesions of miliary tuberculosis. Consequently, pulmonary specialists were consulted and it was decided to start treatment with antitubercular drugs; however, the patient died a day after the beginning of therapy. The autopsy showed a nonspecific chronic granulomatosis, which results were only confirmed 2 months later, when the culture of bronchial secretions was positive (coding 7) for Mycobacterium tuberculosis(AU)

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JUSTIFICATIVA E OBJETIVOS: A reação paradoxal pode ser identificada em até 30% de todos os pacientes após o início de tratamento para tuberculose, embora seu diagnóstico permaneça um desafio, já que não existem testes confiáveis que o corroborem. O objetivo deste estudo foi relatar um caso em que o diagnóstico de reação paradoxal foi realizado.RELATO DO CASO: Paciente do sexo masculino, 31 anos,um mês após o início de uso de fármacos para tratamento de tuberculose miliar, com diagnóstico realizado por lavado broncoalveolar, apresentou plegia no membro inferior direito, parestesia no membro superior direito e membro inferior esquerdo, incontinência urinária e fecal. Ressonância nuclear magnética do encéfalo evidenciou múltiplas áreas com hipersinal em T2, predominando em substância branca subcortical em ambos os hemisférios, com realce de lesões nodulares, sugestivas de infecção oportunista. Antivírus da imunodeficiência humana 1/2 foi negativo. PCR DNA para M. tuberculosis no líquor foi negativa. Iniciou-se, então, dexametasona. O paciente apresentou melhora significativa, porém permaneceu com incontinência urinária.Tomografia computadorizada de crânio realizada posteriormente não evidenciou quaisquer alterações. CONCLUSÃO: Apesar de sua elevada prevalência, continua difícilr ealizar o diagnóstico de reação paradoxal após o início de tratamento para tuberculose. Mais estudos são necessários para melhor definir os parâmetros diagnósticos e para orientar diretrizes terapêuticas mais efetivas.

BACKGROUND AND OBJECTIVES: Paradoxical response can be identified in up to 30% of all patients after initiation of tuberculosis treatment, although your diagnosis still remains a challenge, mainly because do not exist trustworthy tests to confirm it. These study aimed to describe a case were the diagnosis of a paradoxical response was made.CASE REPORT: Male patient, 31 year-old, a month after the initiation of miliary tuberculosis treatment, with the diagnosis realized by bronchoalveolar lavage, presented right lower limb plegia, right upper limb paresthesia, urge and fecal incontinence. Brain Magnetic Resonance Imaging evidenced hyper signs of T2 in multiple areas, in which predominated in white subcortical substance, beyond enhancing nodular lesions, suggesting an opportunistic infection. Anti human immunodeficiency virus 1/2 was negative. PCR DNA to M. tuberculosis in liquor was negative. After, dexamethasone treatment was started. The patient presented a significant improvement, but urge incontinence remained unchanged. Brain computed tomography realized after not evidence any alteration. CONCLUSION: Despite paradoxical response presents high occurrence, it continuous to be difficult to make the diagnosis of paradoxical response after initiation of tuberculosis treatment. Further studies are necessary in order to improve the diagnostic parameters and to orientate more effective therapeutic consensus.

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Mycobacterium tuberculosis infection in patients with autosomal dominant polycystic kidney disease (ADPKD) is rare, and its diagnosis and treatment are difficult because numerous cysts are exposed to infection and antibiotics do not easily penetrate infected cysts. Here, we report the case of a 43-year-old Japanese man with disseminated urogenital tuberculosis (TB) and ADPKD without human immunodeficiency virus (HIV) infection. Delayed diagnosis and ineffective anti-TB chemotherapy worsened his condition. Finally, he underwent bilateral nephrectomy but experienced postoperative complications. In conclusion, kidney TB should be recognized as a cause of renal infection in ADPKD, and surgical treatment should be instituted without delay. The importance of early diagnosis and treatment cannot be overemphasized to prevent kidney TB deterioration.

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Pneumothorax is a common complication in pulmonary tuberculosis that is usually seen with underlying cavitary lesion. However, it is uncommonly seen in patients with miliary tuberculosis. This communication describes bilateral spontaneous pneumothorax in an 18 years' old female patient having miliary tuberculosis.

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We report a case of a 65-year-old Korean female patient with rheumatoid arthritis, who presented with extensive necrotizing fasciitis of the gluteus muscles, as an unusual initial manifestation of miliary tuberculosis. The patient had been previously treated with conventional disease-modifying antirheumatic drugs and low-dose steroids for 7 years. However, she recently developed fever, warmth and painful swelling in her right buttock. Magnetic resonance imaging indicated necrotizing fasciitis of the gluteus muscles and a fasciectomy specimen revealed a Mycobacterium tuberculosis infection. Two weeks after a fasciectomy, miliary tuberculosis of the lung was diagnosed by high resolution chest computed tomography. Soft tissue infection due to M. tuberculosis should be included as a differential diagnosis in the immunocompromised host. Clinicians should be alert to the possibility of miliary tuberculosis even in the absence of respiratory symptoms and normal chest radiograph.

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A 56-year-old woman with ankylosing spondylitis, treated for 3 months with infliximab, developed miliary tuberculosis with mediastinal lymphadenopathies and brain and splenic lesions. After initial improvement under anti-tuberculous therapy, she suffered an unexpectedly prolonged paradoxical worsening with several episodes of lymphadenopathy, including life-threatening ones, over a period of more than 14 months of follow-up. The outcome was favorable as a result of corticosteroid and surgical treatments. This phenomenon reflects a paradoxical reaction precipitated by infliximab withdrawal.

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