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• W2022359817 abstract "To the Editor:The adult respiratory distress syndrome could rarely be due to miliary tuberculosis. I would like to report a case of miliary tuberculosis in a patient with a well-functioning cadaveric kidney transplant who went on to develop the adult respiratory distress syndrome.CASE REPORTA 46-year-old black man was admitted to the transplant service of the Hines (Ill) Veterans Administration Hospital because of increasing shortness of breath, fever, and generalized weakness of three days' duration. He had received a cadaveric kidney three years prior to this admission. The patient was receiving therapy with prednisone (15 mg daily) and azathioprine (Imuran; 175 mg daily). Vital signs were as follows: blood pressure, 150/90 mm Hg; pulse rate, 90 beats per minute; respiration rate, 35/min; and oral temperature, 37.8°C (100°F). Careful physical examination, including the throat, skin, and ears, showed no source of infection. Heart failure and pulmonary disease were ruled out upon physical examination.Relevant laboratory values were as follows: leukocyte count, 8,000/cu mm; hematocrit reading, 40 percent; platelet count, 125,000/cu mm; blood urea nitrogen level, 10 mg/100 ml; and serum creatinine level, 1.3 mg/100 ml. Urinalysis disclosed a pH of 7, a specific gravity of 1.022, a 2+ level of glucose, and 20 to 25 white blood cells per high-power field. Cultures of blood and urine for bacterial and fungal pathogens were negative. A chest x-ray film showed haziness of the left base, which was unchanged from the previous chest x-ray films. The arterial blood gas levels with the patient breathing room air were as follows: pH, 7.50; arterial carbon dioxide tension, 24 mm Hg; arterial oxygen pressure (PaO2), 62 mm Hg; and bicarbonate level, 22 mEq/L. Bacterial and fungal cultures of bronchial washings were negative. A percutaneous biopsy of the liver was done on the tenth day of hospitalization because of rising levels of hepatic enzymes. Caseating granulomas were noted in the specimen from liver biopsy.In spite of antituberculous therapy, the patient's clinical condition rapidly worsened. Dyspnea, with a PaO2 of less than 60 mm Hg, in spite of therapy with increasing positive end-expiratory pressure and a fractional concentration of oxygen in the inspired gas of 100 percent, resulted in a respiratory arrest, from which the patient could not be resuscitated. Chest x-ray films showed a bilateral alveolar infiltrate, with no change in cardiac size or increased pulmonary vasculature. Miliary nodules were present in the lung, liver, and spleen; and acid-fast bacilli were found in the nodules in the postmortem examination.DISCUSSIONMiliary tuberculosis is a rare but potentially treatable cause of the adult respiratory distress syndrome. Dyspnea was the main initial complaint in this case. The first clue to the presence of miliary tuberculosis was the presence of granulomas in the liver biopsy. Disseminated intravascular consumption coagulopathy, which has been reported in a high incidence of patients with miliary tuberculosis, was not present. A high degree of suspicion for this diagnosis is needed in an atypical case of the adult respiratory distress syndrome in a transplant recipient. Cultures of urine for acid-fast bacilli when sterile pyuria is present and aggressive measures for histologic diagnosis, such as biopsies of the liver and lung (when feasible), would enable one to make an earlier diagnosis in this lethal but potentially reversible infectious complication in an immunosuppressed host like a transplant recipient. To the Editor: The adult respiratory distress syndrome could rarely be due to miliary tuberculosis. I would like to report a case of miliary tuberculosis in a patient with a well-functioning cadaveric kidney transplant who went on to develop the adult respiratory distress syndrome. CASE REPORTA 46-year-old black man was admitted to the transplant service of the Hines (Ill) Veterans Administration Hospital because of increasing shortness of breath, fever, and generalized weakness of three days' duration. He had received a cadaveric kidney three years prior to this admission. The patient was receiving therapy with prednisone (15 mg daily) and azathioprine (Imuran; 175 mg daily). Vital signs were as follows: blood pressure, 150/90 mm Hg; pulse rate, 90 beats per minute; respiration rate, 35/min; and oral temperature, 37.8°C (100°F). Careful physical examination, including the throat, skin, and ears, showed no source of infection. Heart failure and pulmonary disease were ruled out upon physical examination.Relevant laboratory values were as follows: leukocyte count, 8,000/cu mm; hematocrit reading, 40 percent; platelet count, 125,000/cu mm; blood urea nitrogen level, 10 mg/100 ml; and serum creatinine level, 1.3 mg/100 ml. Urinalysis disclosed a pH of 7, a specific gravity of 1.022, a 2+ level of glucose, and 20 to 25 white blood cells per high-power field. Cultures of blood and urine for bacterial and fungal pathogens were negative. A chest x-ray film showed haziness of the left base, which was unchanged from the previous chest x-ray films. The arterial blood gas levels with the patient breathing room air were as follows: pH, 7.50; arterial carbon dioxide tension, 24 mm Hg; arterial oxygen pressure (PaO2), 62 mm Hg; and bicarbonate level, 22 mEq/L. Bacterial and fungal cultures of bronchial washings were negative. A percutaneous biopsy of the liver was done on the tenth day of hospitalization because of rising levels of hepatic enzymes. Caseating granulomas were noted in the specimen from liver biopsy.In spite of antituberculous therapy, the patient's clinical condition rapidly worsened. Dyspnea, with a PaO2 of less than 60 mm Hg, in spite of therapy with increasing positive end-expiratory pressure and a fractional concentration of oxygen in the inspired gas of 100 percent, resulted in a respiratory arrest, from which the patient could not be resuscitated. Chest x-ray films showed a bilateral alveolar infiltrate, with no change in cardiac size or increased pulmonary vasculature. Miliary nodules were present in the lung, liver, and spleen; and acid-fast bacilli were found in the nodules in the postmortem examination. A 46-year-old black man was admitted to the transplant service of the Hines (Ill) Veterans Administration Hospital because of increasing shortness of breath, fever, and generalized weakness of three days' duration. He had received a cadaveric kidney three years prior to this admission. The patient was receiving therapy with prednisone (15 mg daily) and azathioprine (Imuran; 175 mg daily). Vital signs were as follows: blood pressure, 150/90 mm Hg; pulse rate, 90 beats per minute; respiration rate, 35/min; and oral temperature, 37.8°C (100°F). Careful physical examination, including the throat, skin, and ears, showed no source of infection. Heart failure and pulmonary disease were ruled out upon physical examination. Relevant laboratory values were as follows: leukocyte count, 8,000/cu mm; hematocrit reading, 40 percent; platelet count, 125,000/cu mm; blood urea nitrogen level, 10 mg/100 ml; and serum creatinine level, 1.3 mg/100 ml. Urinalysis disclosed a pH of 7, a specific gravity of 1.022, a 2+ level of glucose, and 20 to 25 white blood cells per high-power field. Cultures of blood and urine for bacterial and fungal pathogens were negative. A chest x-ray film showed haziness of the left base, which was unchanged from the previous chest x-ray films. The arterial blood gas levels with the patient breathing room air were as follows: pH, 7.50; arterial carbon dioxide tension, 24 mm Hg; arterial oxygen pressure (PaO2), 62 mm Hg; and bicarbonate level, 22 mEq/L. Bacterial and fungal cultures of bronchial washings were negative. A percutaneous biopsy of the liver was done on the tenth day of hospitalization because of rising levels of hepatic enzymes. Caseating granulomas were noted in the specimen from liver biopsy. In spite of antituberculous therapy, the patient's clinical condition rapidly worsened. Dyspnea, with a PaO2 of less than 60 mm Hg, in spite of therapy with increasing positive end-expiratory pressure and a fractional concentration of oxygen in the inspired gas of 100 percent, resulted in a respiratory arrest, from which the patient could not be resuscitated. Chest x-ray films showed a bilateral alveolar infiltrate, with no change in cardiac size or increased pulmonary vasculature. Miliary nodules were present in the lung, liver, and spleen; and acid-fast bacilli were found in the nodules in the postmortem examination. DISCUSSIONMiliary tuberculosis is a rare but potentially treatable cause of the adult respiratory distress syndrome. Dyspnea was the main initial complaint in this case. The first clue to the presence of miliary tuberculosis was the presence of granulomas in the liver biopsy. Disseminated intravascular consumption coagulopathy, which has been reported in a high incidence of patients with miliary tuberculosis, was not present. A high degree of suspicion for this diagnosis is needed in an atypical case of the adult respiratory distress syndrome in a transplant recipient. Cultures of urine for acid-fast bacilli when sterile pyuria is present and aggressive measures for histologic diagnosis, such as biopsies of the liver and lung (when feasible), would enable one to make an earlier diagnosis in this lethal but potentially reversible infectious complication in an immunosuppressed host like a transplant recipient. Miliary tuberculosis is a rare but potentially treatable cause of the adult respiratory distress syndrome. Dyspnea was the main initial complaint in this case. The first clue to the presence of miliary tuberculosis was the presence of granulomas in the liver biopsy. Disseminated intravascular consumption coagulopathy, which has been reported in a high incidence of patients with miliary tuberculosis, was not present. A high degree of suspicion for this diagnosis is needed in an atypical case of the adult respiratory distress syndrome in a transplant recipient. Cultures of urine for acid-fast bacilli when sterile pyuria is present and aggressive measures for histologic diagnosis, such as biopsies of the liver and lung (when feasible), would enable one to make an earlier diagnosis in this lethal but potentially reversible infectious complication in an immunosuppressed host like a transplant recipient." @default.
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• W2022359817 title "Miliary Tuberculosis and the Adult Respiratory Distress Syndrome in a Renal Transplant Recipient" @default.
• W2022359817 doi "https://doi.org/10.1378/chest.75.3.412-b" @default.
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