Disseminated tuberculosis

• Alternative Names

  Miliary tuberculosis; Tuberculosis - disseminated; Extrapulmonary tuberculosis

• Causes, incidence, and risk factors

  Tuberculosis (TB) infection can develop after inhaling droplets sprayed into the air from a cough or sneeze by someone infected with the Mycobacterium tuberculosis bacteria. Small areas of infection, called granulomas (granular tumors), develop in the lungs.

  The usual site of tuberculosis is the lungs, but other organs can be involved. In the U.S., most people with primary tuberculous get better and have no further evidence of disease. Disseminated disease develops in the small number of infected people whose immune systems do not successfully contain the primary infection.

  Disseminated disease can occur within weeks after the primary infection, or may lie dormant for years before causing illness. Infants, the elderly, those infected with HIV. and those who take immune-suppressing medications are at higher risk for the disease worsening, because of their weaker immune systems.

  In disseminated disease, organs and tissues affected can include:

  • Bones and joints
  • Bronchus
  • Cervical lymph nodes
  • Eye
  • Larynx (voice box)
  • Lining of the abdominal cavity (peritoneum)
  • Lining of the brain and spinal cord (meninges)
  • Lining of the heart (pericardium)
  • Organs of the male or female urinary and reproductive systems
  • Skin
  • Small bowel
  • Stomach

  The risk of catching TB increases when you are in contact with people who have the disease, if you live in crowded or unsanitary conditions, and if you have poor nutrition.

  Recently, TB has been seen more often in the U.S. Factors that may be causing this increase are tuberculosis infections in people with AIDS and HIV, and increasing numbers of homeless people.

  Another matter of concern is the development of drug-resistant strains of TB. Incomplete treatment of TB infections (such as not taking medications for the prescribed length of time) can contribute to the development of drug-resistant strains of bacteria.

  About half of AIDS patients with a CD4 count less than 200 who develop TB will have disseminated disease (not localized disease, as in pulmonary tuberculosis).

• Symptoms

  The primary infection usually has no symptoms.

  Symptoms of disseminated tuberculosis include:

  • Cough
  • Fatigue
  • Fever
  • General discomfort, uneasiness, or ill feeling (malaise)
  • Shortness of breath
  • Sweating
  • Weight loss

  Other symptoms that can occur with this disease:

  • Abdominal swelling
  • Chills
  • Joint pain
  • Pale skin due to anemia (pallor)
  • Swollen glands

  Note: The symptoms will depend upon the affected areas of the body.

• Signs and tests

  A physical exam may show:

  • Swollen liver
  • Swollen lymph nodes
  • Swollen spleen

  Tests for tuberculosis include:

  • Biopsies and cultures of affected organs or tissues
  • Bronchoscopy for biopsy or culture
  • Chest x-ray
  • Fundoscopy may reveal retinal lesions
  • Open lung biopsy
  • Pleural biopsy
  • Sputum cultures
  • Tuberculin skin test

  This disease may also alter the results of the following tests:

  • Mycobacterial culture of bone marrow
  • Peripheral smear
  • Serum calcium (may be elevated)
• Treatment

  The goal of treatment is to cure the infection with drugs that fight the TB bacteria. Treatment of active pulmonary TB will always involve a combination of many drugs (usually four drugs). All of the drugs are continued until lab tests show which medicines work best.

  The most commonly used drugs include:

  • Isonizid
  • Rifampin
  • Pyrazinamide
  • Ethambutol

  Other drugs that may be used to treat TB include:

  • Amikacin
  • Ethionamide
  • Moxifloxacin
  • Para-aminosalicylic acid
  • Streptomycin

  You may need to take many different pills at different times of the day for 1 year or longer. It is very important that you take the pills the way your health care provider instructed.

  When people do not take their tuberculosis medications as recommended, the infection becomes much more difficult to treat. The TB bacteria may become resistant to treatment, and sometimes, the drugs no longer help treat the infection. For atypical tuberculosis infections, or drug-resistant strains, other drugs may be used to treat the infection.

  When there is a concern that a patient may not take all the medication as directed, a health care provider may need to watch the person take the prescribed drugs. This is called directly observed therapy. In this case, drugs may be given 2 or 3 times per week, as prescribed by a doctor.

  You may need to be admitted to a hospital for 2 - 4 weeks to avoid spreading the disease to others until you are no longer contagious.

  Your doctor or nurse is required by law to report your TB illness to the local health department. Your health care team will be sure that you receive the best care for your TB.

• Expectations (prognosis)

  Most disseminated forms of TB respond well to treatment.

• Complications

  Complications of disseminated TV can include:

  • Adult respiratory distress syndrome (ARDS)
  • Lung failure
  • Relapse of the disease

  Medicines used to treat TB may cause side effects, including liver problems. Other side effects include:

  • Changes in vision
  • Orange- or brown-colored tears and urine
  • Rash

  A vision test may be done before treatment so your doctor can monitor any changes in your eyes' health over time.

• Calling your health care provider

  Call your health care provider if you know or suspect that you have been exposed to TB. All forms of TB need prompt evaluation and treatment.

• Prevention

  TB is a preventable disease, even in those who have been exposed to an infected person. Skin testing (PPD) for TB is used in high risk populations or in people who may have been exposed to TB, such as health care workers.

  A positive skin test indicates TB exposure and an inactive infection. Discuss preventive therapy with your doctor. People who have been exposed to TB should be skin tested immediately and have a follow-up test at a later date, if the first test is negative.

  Prompt treatment is extremely important in controlling the spread of TB from those who have active TB disease to those who have never been infected with TB.

  Some countries with a high incidence of TB give people a vaccination (called BCG) to prevent TB. However, the effectiveness of this vaccine is controversial and it is not routinely used in the United States.

  People who have had BCG may still be skin tested for TB. Discuss the test results (if positive) with your doctor.

• References

  Iseman DE. Tuberculosis. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 345.

Review Date: 12/1/2009

Reviewed By: David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine; Jatin M. Vyas, MD, PhD, Assistant Professor in Medicine, Harvard Medical School, Assistant in Medicine, Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.