PMC5478571_01
Computed tomography images of the development of miliary tuberculosis according to the lobes of the lung. Chest computed tomography (CT) scan on Day 1 showing chronic interstitial pneumonia (A). Chest CT scan on Day 6 showing bilateral, widespread, patchy, ill-defined lung opacification, and interlobular septal thickening, with no clear miliary lesion (B). Chest CT scan on Day 18 clearly showing miliary lesions, especially in the upper lobe (C).
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Australia) were positive. A computed tomography (CT) scan showed chronic interstitial pneumonia in the chest (Fig. 1A) and gallstones and thickening of the gallbladder wall in the abdomen. ARDS according to the Berlin Definition. A chest CT scan showed bilateral, widespread, patchy, ill-defined lung opacification and interlobular septal thickening, but there were no clear miliary lesions (Fig. 1B). At that point, miliary lesions became apparent on a chest CT scan (Fig. 1C).
Clinical course, laboratory, and radiological findings. A bone marrow biopsy of the anterior superior iliac spine was performed on Day 15 under mechanical ventilation. A diagnosis of tuberculosis was rapidly obtained. Her respiratory condition and fever improved soon after she was administered anti-TB drugs on Day 18. INH: isoniazid, RBT: rifabutin, PZA: pyrazinamide, SM: streptomycin, TB: tuberculosis, CT: computed tomography, mPSL: methylprednisolone, PSL: prednisolone, BT: body temperature, CRP: C-reactive protein, P/F ratio: partial pressure of arterial oxygen/fraction of inspired oxygen
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Her P/F ratio increased to 305 mmHg, and the fever improved soon after she was administered anti-TB drugs on Day 18 (Fig. 2). The clinical course, laboratory, and radiological findings are shown in Fig. 2.
Pathological findings. Macroscopically, collapsed air space with necrosis and granuloma presents as a heavy and hard lung (a, b). Loupe images of the lung show the hyaline membrane along the alveolar ducts (c: x4, d: x10) and severe inflammation (e: Hematoxylin and Eosin staining x1.25 f: elastica van Gieson x1.25). Miliary nodules in the lung consisted of unstructured granulomas and Langhans giant cells with acid fast bacteria identified by Truant's Auramine-Rhodamine stain (g: x10, h: x10). Poorly formed granulomas were distributed around the bronchiole, which is probably the origin of the tuberculosis discharge (i: x1.25 j: x4). Typical granulomas with large caseous necrosis were found in the lymph nodes (k: x4, l: x1.25). Distributed granulomas were present around Glisson's capsule in the liver, which appeared normal macroscopically (m, n: x4).
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The details of the pathological findings are shown in Fig. 3.