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Case Reports and Small Case Series
July 1998

Miliary Tuberculosis

Arch Ophthalmol. 1998;116(7):953-954. doi:

A 31-year-old male-to-female transsexual prostitute, a recent immigrant from Mexico, came to the emergency department disoriented and with an elevated temperature. Medical history was notable for recent purified protein derivative positivity on skin testing. A chest x-ray film at examination showed fine miliary opacities in all lung fields (Figure 1). A computed tomographic scan of the head revealed prominent meningeal vascularity and multiple supratentorial and infratentorial enhancing lesions (Figure 2). A lumbar puncture specimen contained 618 white blood cells, of which 0.84 were neutrophils; 0.12, monocytes; and 0.04, lymphocytes. The diagnosis was presumed Mycobacterium tuberculosis infection and the patient was admitted for therapy with 4 drugs that included isoniazide, rifampin, ethambutol hydrochloride, and pyrizinimide. On the second hospital day, the ophthalmology service was asked to see the patient because of blurred vision of 2 months' duration. The patient was lethargic, with a best-corrected visual acuity of 20/40 in each eye. No afferent pupillary defect was present. External and anterior segment examination findings were normal. Fundus examination findings revealed multiple choroidal infiltrates involving the posterior pole in each eye (Figure 3, A, B). Serial fluorescein angiography showed early blockage and late staining of these lesions (Figure 3, C-G). Cultures from sputum and cerebrospinal fluid (Figure 4) grew M tuberculosis. The patient showed slow resolution of the multifocal choroiditis and improvement of mental status and visual acuity with continued treatment.

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