Miliary Tuberculosis
A 56-year-old man presented to the emergency department with a 2-month history of fatigue, weight loss of 10 kg, night sweats, and fever. He had a cough producing sputum that was occasionally blood-tinged. He had immigrated to the United States from Haiti 10 years earlier. On examination, his temperature was 36.2°C. He was breathing comfortably but appeared cachectic. On auscultation, the volume of airflow was equal in both lungs without crackles or wheeze. Dilated funduscopy showed polymorphic yellow lesions with indiscrete borders in the posterior poles of both eyes. Chest radiography revealed widely distributed nodules of uniform size throughout both lung fields, a finding that was consistent with miliary tuberculosis. The ocular findings were consistent with choroidal tubercles. A sputum sample was smear-positive for acid-fast bacilli. The patient began receiving combination therapy with rifampin, isoniazid, pyrazinamide, and ethambutol. After 1 week of therapy, a repeat sputum sample was smear-negative for acid-fast bacilli. Pan-sensitive Mycobacterium tuberculosis was cultured from the initial sputum sample after 6 weeks. After the initiation of treatment, the patient’s symptoms improved, and he completed 6 months of therapy.