Abstract Introduction Miliary tuberculosis (TB) is a rare, disseminated form of TB most commonly seen in immunocompromised individuals. It has long posed a diagnostic challenge for clinicians given its wide range of presentations. We report the case of an immunocompetent patient with new-onset seizures that was subsequently diagnosed with miliary TB with central nervous system (CNS) involvement. Clinical Case A 72-year-old woman with a history of paroxysmal atrial fibrillation on anticoagulation presented to the Emergency Department for evaluation after sustaining a mechanical fall at home with head trauma. An unenhanced CT brain on admission showed chronic white matter changes with no acute intracranial pathology. Initial laboratory studies found leukopenia (WBC 1700/µL) but were otherwise unremarkable. Shortly following hospitalization, the patient developed a focal-to-generalized tonic-clonic seizure that subsided with intravenous benzodiazepines. The patient was intubated for airway protection and transferred to the intensive care unit for further management. MRI brain demonstrated multiple ring-enhancing intracranial lesions involving the supra- and infra-tentorial compartments with surrounding vasogenic edema. CT chest showed innumerable centrilobular micronodules in both lungs. She underwent a lumbar puncture. Cerebrospinal fluid (CSF) studies revealed a WBC 90/µL (100% lymphocytic), glucose 25 mg/dL, and protein 55 mg/dL. Bronchoscopy was also performed, and bronchoalveolar lavage (BAL) samples were sent for microbiologic studies. While patient’s gamma interferon test came back indeterminate, mycobacterium tuberculosis PCRs on both BAL and CSF samples were positive. HIV testing was negative. The patient was started on standard treatment regimen for TB (isoniazid, rifampin, pyrazinamide, ethambutol), as well as anti-epileptics and glucocorticoids. The patient’s clinical course, however, showed minimal improvement with failed attempts to wean patient off mechanical ventilation. Given patient’s poor functional status and overall poor prognosis, the decision was made by family members to withdraw care under hospice, after which patient expired. Discussion Miliary TB has on rare occasions been identified in immunocompetent individuals. While pulmonary involvement is more common with miliary TB, patients may initially present with atypical symptoms secondary to extrapulmonary involvement. Our case demonstrates that seizures may represent CNS involvement of miliary TB, even in the absence of respiratory symptoms. Given the high morbidity and mortality of miliary TB, this case highlights the importance of keeping a high index of suspicion for TB in the appropriate clinical context to prevent treatment delay. This abstract is funded by: None
Hassani et al. (Fri,) studied this question.