Miliary tuberculosis presenting with acute respiratory distress syndrome in a patient with Down syndrome

Ljiljana  Novković; Zorica Lazić; Marina Petrović; Ana Vujić; Andjelka Stojković; Ivan Čekerevac

doi:10.2298/VSP180129108N

Ljiljana Novković University of Kragujevac, Faculty of Medical Science, Clinical Centre Kragujevac, Clinic for Pulmonology, Kragujevac, Serbia
Zorica Lazić University of Kragujevac, Faculty of Medical Science, Clinical Centre Kragujevac, Clinic for Pulmonology, Kragujevac, Serbia
Marina Petrović University of Kragujevac, Faculty of Medical Science, Clinical Centre Kragujevac, Clinic for Pulmonology, Kragujevac, Serbia
Ana Vujić University of Kragujevac, Faculty of Medical Science, Clinical Centre Kragujevac, Department of Pediatrics, Kragujevac, Serbia
Andjelka Stojković University of Kragujevac, Faculty of Medical Science, Clinical Centre Kragujevac, Department of Pediatrics, Kragujevac, Serbia
Ivan Čekerevac University of Kragujevac, Faculty of Medical Science, Clinical Centre Kragujevac, Department of Pediatrics, Kragujevac, Serbia

DOI: https://doi.org/10.2298/VSP180129108N

Keywords: down syndrome, tuberculosis, miliary, respiratory distress syndrome, adult

Abstract

Introduction. Miliary tuberculosis (TB) is a rare and potentially fatal form of disseminated TB. It is caused by a widespread haematogenous dissemination of Mycobacterium tuberculosis from an active caseous focus to different organs. Sometimes it can have an acute presentation with a rapid-onset clinical deterioration and death. Miliary TB complicated with an acute respiratory distress syndrome (ARDS) requiring mechanical ventilation (MV) is rare, even in countries with a high incidence of TB. Case report. A 35-year-old woman with Down syndrome (DS) was admitted to the Clinic for Pulmonology, Clinical Centre Kragujevac, due to an evaluation of cough and weight loss during last 2 months. Laboratory findings revealed anaemia, leukocytosis, elevated C-reactive protein (CRP) and hypoalbuminemia. A chest x-ray showed bilateral reticulonodular shadows, predominantly in the mid and lower right lung lobes. A purified protein derivative (PPD) skin test and induced sputum smear for acid-fast bacilli (AFB) were both negative. On the fifth day following admission, her health condition suddenly declined, and after developing a moderate ARDS, she was put on the mechanical ventilation. Due to a high clinical suspicion of miliary TB and the fact that her life was compromised, an empirical anti-tuberculosis therapy was initiated. Despite all therapeutic and supportive measures, the patient expired 3 days later. The diagnosis of miliary TB was established post-mortem. Conclusion. Miliary TB should be kept in mind in patients with DS due to immunosuppression associated with deficient cell-mediated immunity. The development of ARDS as a complication of miliary TB is difficult to identify due to a low causal association. High clinical suspicion and a chest radiograph with a typical appearance of miliary pattern justify the initiation of empirical anti-tuberculosis treatment in such patients, as an attempt to change poor prognosis.

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