1990 Volume 65 Issue 4 Pages 273-283
Seven cases of miliary tuberculosis in patients with hematologic disease were analyzed clinicopathologically.
Mean age of the patients was 65 years, and the hematologic diseases were CML, AML, ALL, MDS and malignant lymphoma.Diabetes mellitus was present as a complication in three patients.Miliary tuberculosis was found in 5 cases during the first admission to our hospital owing to hematologic problems.In 4 of 6 cases, fever had started more than two months before admission, consequently, the tuberculosis probably began about that time. After admission, chemotherapy was administered in 5 cases, and steroid in 6 cases for hematologic disease.The mean total quantity of steroid administered was 2, 134mg of prednisolone and average treatment duration was 69 days.The chest roentgenographic shadow was so atypical that miliary tuberculosis was suspected in only one case. The initial chest roentgenogram showed hilar and mediastinal lymph node swelling as well as the shadow of pulmonary tuberculosis in two cases.It was thought that the hilar and mediastinal lymph node swelling could be explained by primary complex, although the patients were of advanced age, or by “secondary complex” reported by Terplan, K in 1940. The diagnosis of tuberculosis was made in two patients before their death by smear of aspirated fliud of cervical lymph node and by bone marrow cell block in one patients, and by pathological examination of mediastinal lymph node biopsy in the other patients. Tubercles were found from bone marrow cell block in 2 out of 5 patients and from bone marrow biopsy in 1 out of 3 patients, but the positive results were reported in 2 patients following death.Smears of sputum, gastric juice, urine, spinal fluid and pleural effusion were negative in all cases.One patient diagnosed as miliary tuberculosis also had pneumocystis carinii pneumonia.This case was treated with antituberculosis drugs for 20 days without improvement.Another patient diagnosed as miliary tuberculosis improved under treatment with antituberculosis drugs, but died of cytomegalovirus pneumonia. Autopsy in 5 cases revealed non-reactive miliary tuberculosis, and pulmonary hemorrhage probably due to DIC was present as a complication in two cases.
In these cases, severe immunosuppression, which is a major precipitating factor of miliary tuberculosis, is thought to be induced by hematologic disease itself, chemotherapy, steroid or other underlying disease such as diabetes mellitus.Miliary tuberculosis in such compromised host is cryptic and progresses rapidly.Consequently, early diagnosis is very important.Retrospectively, the unexplained pyrexia was most important to suspect tuberculosis.Examination of bone marrow cell block is considered to be the diagnostic procedure of choice to diagnose cryptic miliary tuberculosis in patients with hematologic disease.And therapeutic administration with antituberculosis drugs should be tried for a few months, when the cause of fever of unknown origin cannot be clarified.
