A Life-saving Journey: Miliary Tuberculosis as ARDS in a Newly Diagnosed AIDS Patient – Early TB Treatment Enables VV ECMO Weaning

Abstract Introduction Miliary tuberculosis (TB) is a severe form characterized by hematogenous dissemination of Mycobacterium tuberculosis, often life-threatening. Complications like acute respiratory distress syndrome (ARDS) and septic shock significantly increase mortality, highlighting the need for prompt diagnosis and management. This report discusses a case of severe ARDS from miliary TB in a newly diagnosed acquired immunodeficiency syndrome (AIDS) patient, highlighting management complexities and the effective use of anti-tuberculous therapy alongside veno-venous extracorporeal membrane oxygenation (VV-ECMO), resulting in successful ECMO weaning. Case report A 31-year-old male with no prior systemic disease presented with two months of progressive malaise, dysphagia, anorexia, fever with evening spikes, night sweats, and a 15 kg weight loss. He experienced worsening exertional dyspnea and dry cough before admission, leading to an emergency department visit. Upon presentation, he exhibited desaturation and hypotension. Chest X-ray showed bilateral micronodular opacities (miliary pattern). Laboratory tests indicated pancytopenia, disseminated intravascular coagulation (DIC), acute kidney injury (AKI), acute liver injury and lactic acidosis. His condition rapidly deteriorated, with follow-up imaging suggesting ARDS and septic shock with multiorgan failure, prompting transfer to the Intensive Care Unit (ICU). In the ICU, the patient's PaO2/FiO2 ratio declined despite lung protective strategies and prone positioning, necessitating VV-ECMO for respiratory support. Sputum cultures were positive for acid-fast bacilli, with no other bacteria detected, and Mycobacterium tuberculosis PCR testing confirmed the diagnosis. Positive acid-fast stains were also found in gastric fluid, stool, and urine. Human immunodeficiency virus testing was positive with a CD4 count under 50. Initially, broad-spectrum antibiotics, including meropenem, were administered. Due to poor digestion and severe liver dysfunction, standard oral anti-tuberculosis medications could not be administered. Therefore, second-line anti-TB therapy with amikacin and levofloxacin were initiated, along with steroids upon ICU admission. After 10 days on ECMO, the patient demonstrated rapid improvement in the PaO2/FiO2 ratio and imaging results, allowing for successful weaning from ECMO. Following significant improvement in liver function and digestion, he was transitioned to an oral four-drug anti-TB regimen and initiated antiretroviral therapy. Although successfully weaned ECMO, he requires ongoing monitoring and treatment for complete recovery. Discussion Challenges in initiating first-line anti-TB therapy arose due to poor oral absorption and organ dysfunction. While the timely initiation of injectable anti-TB medications led to significant clinical improvement, careful monitoring is essential. Consulting with infectious disease and tuberculosis specialists is critical to balance the benefits of early treatment against potential risks associated with compromised organ function.