Beyond the Lungs: A Complex Case of Disseminated Tuberculosis With Multi-organ Involvement and Neurological Sequelae in a Young Male Inmate

Abstract Introduction Disseminated tuberculosis is the presence of Mycobacterium tuberculosis in two or more non-contiguous organs. It is a rare disease with a myriad of presentations based on the organs involved. Case Presentation A 27-year-old inmate with no chronic illnesses presented with a 7-month history of dyspnea, non-productive cough, and weight loss. Chest x-rays revealed consolidation bilaterally. The Mantoux test was positive at 18 mm. Computed tomography (CT) chest revealed diffuse tree-in-bud appearance, bilateral pleural effusions, right pleural thickening, and right hilar lymphadenopathy. These findings suggested pulmonary tuberculosis (TB). CT abdomen revealed bilateral psoas abscesses, perihepatic fluid, and microabscesses in the liver and spleen. Aspirates of the psoas abscess and the perihepatic collection yielded acid-fast bacilli on smear, and PCR assays confirmed TB. The HIV test was negative. The patient was diagnosed with disseminated tuberculosis. Rifampicin, Isoniazid, Pyrazinamide, and Ethambutol (R.I.P.E.) therapy was initiated. The patient began experiencing lower back pain, headaches, right-sided hearing loss, purulent otorrhea, and generalized tonic-clonic seizures. MRI Brain revealed multiple ring-enhancing lesions and right mastoiditis. Findings raised suspicion for tuberculomas in the brain. The TORCH panel indicated past cytomegalovirus and toxoplasmosis infection. MRI of the lumbar spine showed spondylodiscitis, herniation of multiple discs, expansile bony masses to multiple ribs, intraosseous collections, and lytic lesions, suggestive of TB spondylitis and TB osteomyelitis. Despite symptom resolution, interval scans showed a new mediastinal collection and loculated empyema after 1 year. Discussion Disseminated tuberculosis is rare and highly lethal, affecting less than 2% of tuberculosis patients. Mycobacterium tuberculosis replicates in pulmonary macrophages until T-helper cells activate macrophages to control the replication. In immunocompromised patients, weakened cell-mediated immunity allows the bacteria to disseminate by lymphatic and hematogenous routes. Recent studies suggest that suppressed TNF and NF-κB signaling pathways contribute to impaired T cell IFN-γ responses, even in HIV-negative individuals. Disseminated tuberculosis can be confirmed by histopathology, microbiological evidence, and PCR. This case highlighted the complexity associated with diagnosing and managing disseminated tuberculosis. Its nonspecific symptoms and varied presentations often hinder timely diagnosis, enabling extensive multi-organ involvement. Prompt management is critical to prevent long-term complications. Patients with disseminated TB receive the standard R.I.P.E. therapy, with treatment duration adjusted according to the severity of organ involvement. A multidisciplinary approach is crucial for optimal management. Conclusion Disseminated tuberculosis is a rare form of tuberculosis with a wide range of presentations. Early diagnosis and intervention are essential to improve patient outcomes.