CXR is from a patient with Miliary Tuberculosis. How to proceed with the case?

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Miliary TB may occur in an individual organ (very rare, < 5%), in several organs, or throughout the entire body (>90%), including the brain. The infection is characterized by a large amount of TB bacilli, although it may easily be missed and is fatal if left untreated. Up to 25% of patients with miliary TB may have meningeal involvement. In addition, miliary TB may mimic many diseases. In some case series, up to 50% of cases are undiagnosed antemortem. Therefore, a high index of clinical suspicion is important to obtain an early diagnosis and to ensure improved clinical outcomes. Causes for miliary tuberculosis involve immunosuppression. So evaluating and rule out all possibilities is beneficial for good prognosis Cancer Recent Transplantation HIV infection Malnutrition Diabetes ( now many clinical studies says both will grow hand to hand ) Silicosis ( occupational hazard) End-stage renal disease Major surgical procedures - Occasionally may trigger dissemination Differential diagnosis generally we confuse with TB Acute respiratory distress syndrome Blastomycosis Disseminated intravascular coagulation Hypersensitivity pneumonitis Pneumocystis carinii pneumonia Bacterial pneumonia Community-acquired pneumonia Fungal pneumonia Viral pneumonia Pancreatic abscess Pulmonary alveolar microlithiasis Diagnosis workup 1. CBP : leukopenia/leukocytosis may be present in miliary tuberculosis. Leukemoid reactions may occur; patients may have anemia; and thrombocytopenia or, rarely, thrombocytosis may be present. 2.ESR raised in 50% patients 3.gene expert studies Treatment Empirical starting of DOTS regimen And referring patient to TB centre or to pulmonologist or chest physician is better We patient is Diabetes controlling diabetes is first line of treatment

Military t.b involve organs in less than 5%cases.Iris distributed thru put our body in95%cases including brain.25% all military t.b has meaningless involvement.immunosupression usually spreads the disease.all causes of immunosupression should be assessed prior.
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All patients of suspected or confirmed military TB should be tested for HIV status, and in HIV-infected patients with TB, for antiretroviral treatment to be started after the completion of ATT. All patients with disseminated (including miliary) TB should be tested for CNS involvement by CT or MRI of the brain and/or lumbar puncture for those without CNS symptoms and signs. New patients with miliary TB receive 6 months of daily treatment(2-month intensive phase with isoniazid, rifampicin, pyrazinamide, and ethambutol or streptomycin, followed by a 4-month continuation phase with isoniazid, rifampicin,ethambutol). The guidelines mention that some experts recommend 9–12 months of treatment when TBM is present given the serious risk of disability and mortality.

Miliary TB Needs further investigations and evaluation to conclude diagnosis and line of treatment. Maintain nutrition hydration and hygiene. Inj ceftum 1gm IV BD slowly.

Not plastic surgery problem

get ophthalmologist opinion also; start att with steroids; look for immunocompromised condition too

HRCT , Sputum for AFB and CBNATT, rile out DM, HIV , Rule out MDRTB. 5 drug ATT to be started . Improve general condition

Nice post

Firat r/o hiv infection then Sputum afb and cbnaat start akt instead of sputum report positive or negative@