Complications of miliary tuberculosis: low mortality and predictive biomarkers from a UK cohort

Abstract

BackgroundUntreated, miliary tuberculosis (TB) has a mortality approaching 100%. As it is uncommon there is little specific data to guide its management. We report detailed data from a UK cohort of patients with miliary tuberculosis and the associations and predictive ability of admission blood tests with clinical outcomes.MethodsRoutinely collected demographic, clinical, blood, imaging, histopathological and microbiological data were assessed for all patients with miliary TB identified from the London TB register from 2008 to 2012 from Northwest London Hospitals NHS Trust. Multivariable logistic regression was used to assess factors independently associated with the need for critical care intervention. Receiver operator characteristics (ROC) were calculated to assess the discriminatory ability of admission blood tests to predict clinical outcomes.ResultsFifty-two patients were identified with miliary tuberculosis, of whom 29% had confirmed central nervous system (CNS) involvement. Magnetic resonance imaging (MRI) was more sensitive than computed tomography (CT) or lumbar puncture for detecting CNS disease. Severe complications were frequent, with 15% requiring critical care intervention with mechanical ventilation. This was independently associated with admission hyponatraemia and elevated alanine aminotransferase (ALT). Having an admission sodium ≥125 mmol/L and an ALT <180 IU/L had 82% sensitivity and 100% specificity for predicting a favourable outcome with an area under the ROC curve (AUC) of 0.91. Despite the frequency of severe complications, one-year mortality was low at 2%.ConclusionsAlthough severe complications of miliary tuberculosis were frequent, mortality was low with timely access to critical care intervention, anti-tuberculous therapy and possibly corticosteroid use. Clinical outcomes could accurately be predicted using routinely collected biochemistry data.

Neuroimaging Findings in Tuberculosis: A Single‐Center Experience in 559 Cases

“…Generally, MRI has greater sensitivity for diagnosing CNS diseases as compared to CT and LP. 16 However, our results show that CT scans showed more single unilateral chronic infarcts, unilateral supratentorial tuberculomas, and hydrocephalus and cerebral edema. On the other hand, MRI scans showed more multifocal bilateral acute infarcts, infratentorial tuberculomas, basal meningeal enhancement, ventriculitis, cerebritis, and spinal TB.…”

“…Generally, MRI has greater sensitivity for diagnosing CNS diseases as compared to CT and LP . However, our results show that CT scans showed more single unilateral chronic infarcts, unilateral supratentorial tuberculomas, and hydrocephalus and cerebral edema.…”

High blood neutrophil-lymphocyte ratio associated with poor outcomes in miliary tuberculosis

“…High blood neutrophil-lymphocyte ratio associated with poor outcomes in miliary tuberculosis been found to be aging, female sex, presence of underlying comorbidity, hyponatremia, hypoalbuminemia, leukopenia, elevated transaminase level, and poor nutritional status (2,6,(9)(10)(11)(12)(13)(14)(15). However, the aforementioned factors have not demonstrated consistent results.…”

Review of literature on disseminated tuberculosis with emphasis on the focused diagnostic workup

“…In fact, no randomized controlled trials of disseminated TB treatment have been conducted, and most evidence is based on randomized controlled trials of pulmonary TB. [ 72 ] Although there is no consensus regarding the optimum duration of treatment in patients with disseminated TB,[ 47 ] early initiation of therapy is associated with a significant improvement in outcomes. [ 1 73 74 ]…”

“…For example, patients with high organism burden, slow clinical response, immune suppression, CNS infection and certain patients with bone and joint involvement and longer duration of therapy may be needed. [ 72 75 ] For susceptible organisms, treatment of disseminated TB includes the administration of the “four-drug regimen,” which consists of two phases, rifampicin, isoniazid (INH), pyrazinamide, and ethambutol/streptomycin given daily for the first 2 months. The treatment is then continued with rifampicin and isoniazid for a further 4 months, with the possibility of being extended to 7 months in some cases.…”