INTRODUCTION: Tuberculosis remains one of the leading causes of infectious morbidity and mortality in the world today. The presentation of miliary tuberculosis can be varied, ranging from septic shock to chronic illness. We present the case of a patient with tuberculosis involvement of the skin, sternum and ascending aorta resulting in an arterial bleed requiring emergent surgical repair.
CASE PRESENTATION: A 48 year old male from guyana presented to the emergency department with a complaint of profuse bleeding from a chest wall abscess after falling. The abscess had been present for 7 months prior, which the patient had been self treating with epsom salts unsuccessfully. Prior to this admission, he had not received medical care in over 20 years, but has progressively been getting weaker, with weight loss and night sweats for the last year. He denied any exposure to tuberculosis since immigrating to the United States 17 years earlier. Physical exam demonstrated bilateral axilla lymphadenopathy and his anterior chest was significant for a 2 cm and a 1.5 cm round area of abrasion to the right of the sternum over the 3rd intercostal space with associated skin atrophy, hyperpigmentation and erythema. Chest x-ray performed at admission demonstrated a thick wall cavitary lesion in the right upper lobe and bilateral apical cavities. While on the floor he developed a pulsatile bleed from his abscess site. CT of the chest demonstrated a pseudoaneurysm of the brachiocephalic artery extending into the retromanubrial region. A stent to the right subclavian artery was then placed by vascular surgery. The patient was then taken to the operating room for biopsies of lymph nodes and debridement of the anterior chest. Biopsies revealed acid fast bacilli stain positive granulomatous osteomyelitis of the sternum. Sputum cultures demonstrated mycobacterium tuberculosis.
DISCUSSIONS: Uncontrolled hematogenous dissemination of Mycobacterium tuberculosis is referred to as miliary tuberculosis. There is a high degree of variability to the clinical presentation of miliary tuberculosis, from septic shock and acute respiratory distress syndrome, to failure to thrive or fever of unknown origin. Cutaneous disease is rare in miliary tuberculosis. Tuberculosis cutis milaris disseminata, which consists of 5-10 mm macules and papules is the most common presentation of cutaneous tuberculosis. Mycotic aneurysims of the ascending or descending aorta are also associated with disseminated tuberculosis. Embolization to the aortic wall vasa vasorum during hematogenous spread, or spread from a lymph node or vertebral osteomyelitis have been proposed as potential mechanisms for involvement of the aorta. Aneurysm rupture has been reported after the initiation of antituberculos chemotherapy.
CONCLUSION: Tuberculosis remains one of the leading causes of infectious morbidity and mortality in the world today. Though our patient had been living in the United States for the last 17 years, and could not recall any recent contacts with tuberculosis, his birth in an endemic region of the world for tuberculosis placed him at risk for tuberculosis infection. Reactivation tuberculosis can present in it's miliary form, with a wide range of presentations. In this patient, his lack of medical care, and attempts at self-therapy delayed his diagnosis, resulting in the advanced stage of his disease. He was stared on rifampin, isoniazid, pyrazinamide and ethambutol. His repeat sputum cultures are negative,he has been gaining weight, and his wound on his chest has been healing by secondary closure.
DISCLOSURE: Faisal Uddin, No Financial Disclosure Information; No Product/Research Disclosure Information