Disseminated Tuberculosis

Disseminated tuberculosis presents in a non-specific manner [1] because usually several organs are involved at the same time and produce symptoms, therefore the diagnosis can be easily missed, with fatal consequences [2]. Systemic symptoms include fever, fatigability and weight loss and progress for weeks or months [3]. Physical examination reveals cough, splenomegaly, hepatomegaly, generalized lymphadenopathy [4] and signs of multiorgan dysfunction [5]. Genitourinary involvement is common. Kidneys, prostate, testes, epididymis and seminal vesicles may be affected, leading to sterile pyuria and hematuria [6]. Epididymis tuberculosis presents with pain, swelling or a palpable mass in the scrotum. Splenic tuberculosis leads to splenomegaly, nausea, vomiting and abdominal pain [7].

Due to the high degree of non-specificity of the presentation, allopathic medicine relies on the typical finding on a chest radiograph for diagnosis, but this can be absent, leading to the conclusion that a high degree of suspicion must be maintained when facing a patient with prolonged hyperpyrexia of unknown etiology and other often encountered signs [8].

Blood workup should include a complete cell blood count, that may show either leukopenia or leukocytosis, pancytopenia, agranulocytosis, aplastic anemia, leukoerythroblastic anemia, thrombocytopenia or, in rare cases, thrombocytosis. Sodium level may be decreased due to the syndrome of inappropriate secretion of antidiuretic hormone. Alkaline phosphatase level may be increased. High transaminase levels may be caused by hepatic involvement or drug toxicity [9]. Inflammation markers, such as the erythrocyte sedimentation rate are high. Hypoalbuminemia, hypercalcemia and high ferritin levels [10] have also been described.

Mycobacterium tuberculosis is sometimes not found in the cultured sputum of disseminated tuberculosis patients. In such instances, the diagnosis is even more difficult [11] and cultures should be obtained from other sites (blood, cerebral spinal fluid, urine). If the bacteria is isolated, sensitivity testing should be performed. Acid fast bacilli staining should also be performed.

If cerebral symptoms are present, a lumbar puncture should be performed. Analysis may reveal increased leukocyte and lymphocyte counts, elevated protein and low glucose levels.

The tuberculin skin prick test is often negative in disseminated tuberculosis but does not exclude the diagnosis.

Thoracic radiography may show miliary shadowing in some patients, but sensibility and specificity of this finding are considered low [12] [13]. Pleural effusion may also be noticed, while pericardial effusion is better observed with echocardiography and electrocardiography.

Abdominal ultrasound detects hepatomegaly, splenomegaly, abscesses and enlarged lymph nodes, if present. Computer tomography evaluation is even more reliable in this case. The cranium can also be scanned or head magnetic resonance imaging may be performed in cases of suspected lesions and in order to exclude hydrocephalus and tuberculoma. Retinal tubercles may be observed if fundoscopy is performed.

More invasive procedures include fiberoptic bronchoscopy, liver and bone marrow biopsy. They are only recommended in selected cases, as they induce significant discomfort [14]. Liver bleeding after biopsy is potentially life-threatening.

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