Subacute Presentation of Miliary Tuberculosis Leading to Multi-System Organ Failure

Mycobacterium tuberculosis (MTB) is an increasingly rare infectious organism known to cause primary lung infections however, can lead to systemic progression. Miliary TB is an uncommon form of MTB with high mortality resulting from lymphohematogeous dissemination. Findings are classically characterized by multi-organ system involvement and a millet seed-like pattern on radiographic and pathological evaluation. This disseminated presentation likely accounts for approximately 2% of infections.A 42-year-old Nepalese woman with history of treated latent MTB presented to an outside hospital with abdominal distention and pain, fevers, diarrhea, and five-pound weight loss. Computed topography of the abdomen showed hepatosplenomegaly, ascites, enhancing soft tissue nodularity in the right mid-abdomen and omental fat. Paracentesis showed serum ascites albumin gradient of 1.2 and spontaneous bacterial peritonitis (SBP) based off nucleated cells. Cytology for malignancy and acid-fast bacilli (AFB) stain was negative. Patient was transferred to Western Pennsylvania Hospital for gynecological oncology evaluation for suspected ovarian cancer. Transthoracic echocardiogram showed a normal ejection fraction. Liver ultrasound showed normal portal vein flow. Cytomegalovirus, Epstein Barr Virus, hepatitis A, B and C, and HIV were negative. Chronic liver disease workup was unremarkable. Patient developed persistent fevers despite treatment with cefepime, vancomycin, metronidazole, and micafungin. Ascitic fluid testing showed adenosine deaminase of 4.4 and MTB nucleic acid amplification negative. Liver needle biopsy showed severe steatosis with superimposed steatohepatitis, mallory-denk body deposition, and focal neutrophilic satellitosis with severe subsinusoidal bridging fibrosis. Special stains including AFB and PCR for mycobacterium were unrevealing. Patient progressed to multisystem organ failure requiring mechanical ventilation, vasopressor support, and renal replacement therapy from septic shock and liver failure presumed secondary to alcoholic cirrhosis. Formal transplant evaluation was deferred due to underlying malignancy concern. A limited core needle omental biopsy showed AFB and fungal stain negative, necrotizing granulomas. Prior to a surgical based biopsy, the patient developed further respiratory and hemodynamic compromise and passed following terminal extubation. Post-mortem bronchoalveolar lavage results returned positive for MTB. Miliary tuberculosis in developed countries where the overall prevalence of MTB is low is rare. Due to its atypical presentation, invariably with extrapulmonary involvement, there is often a delay in diagnosis. Despite increasingly sensitive modalities and prompt results, there is still room for improvement. While it is an uncommon presentation, this case report serves as a reminder to clinicians to maintain a high index of suspicion for Miliary TB in select immunocompromised patients and those from endemic countries.