Sharma Surendra K, Mohan Alladi, Sharma Animesh
Department of Medicine, All India Institute of Medical Sciences, New Delhi 110 029, India.
Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati 517 507, India.
J Clin Tuberc Other Mycobact Dis. 2016 Mar 18;3:13-27. doi: 10.1016/j.jctube.2016.03.003. eCollection 2016 May.
Miliary tuberculosis (TB), is a fatal form of disseminated TB characterized by tiny tubercles evident on gross pathology similar to innumerable millet seeds in size and appearance. Global HIV/AIDS pandemic and increasing use of immunosuppressive drugs have altered the epidemiology of miliary TB. Keeping in mind its protean manifestations, clinicians should have a low threshold for suspecting miliary TB. Careful physical examination should focus on identifying organ system involvement early, particularly TB meningitis, as this has therapeutic significance. Fundus examination for detecting choroid tubercles can help in early diagnosis as their presence is pathognomonic of miliary TB. Imaging modalities help in recognizing the miliary pattern, define the extent of organ system involvement and facilitate image guided fine-needle aspiration cytology or biopsy from various organ sites. Sputum or BAL fluid examination, pleural, pericardial, peritoneal fluid and cerebrospinal fluid studies, fine needle aspiration cytology or biopsy of the lymph nodes, needle biopsy of the liver, bone marrow aspiration and biopsy, testing of body fluids must be carried out. GeneXpert MTB/RIF, line probe assay, mycobacterial culture and drug-susceptibility testing must be carried out as appropriate and feasible. Treatment of miliary TB should be started at the earliest as this can be life saving. Response to first-line anti-TB drugs is good. Screening and monitoring for complications like acute respiratory distress syndrome (ARDS), adverse drug reactions like drug-induced liver injury, drug-drug interactions, especially in patients co-infected with HIV/AIDS, are warranted. Sparse data are available from randomized controlled trials regarding optimum regimen and duration of anti-TB treatment.
粟粒性肺结核是播散性肺结核的一种致命形式，其特征是在大体病理上可见微小的结核结节，大小和外观类似于无数的粟米种子。全球艾滋病毒/艾滋病大流行以及免疫抑制药物使用的增加改变了粟粒性肺结核的流行病学。鉴于其多变的表现形式，临床医生对粟粒性肺结核的怀疑阈值应较低。仔细的体格检查应着重于早期识别器官系统受累情况，尤其是结核性脑膜炎，因为这具有治疗意义。眼底检查以检测脉络膜结核结节有助于早期诊断，因为其存在是粟粒性肺结核的特征性表现。影像学检查有助于识别粟粒样病变模式，确定器官系统受累程度，并便于在影像引导下从各个器官部位进行细针穿刺细胞学检查或活检。必须进行痰液或支气管肺泡灌洗（BAL）液检查、胸膜、心包、腹腔积液和脑脊液检查、淋巴结细针穿刺细胞学检查或活检、肝脏穿刺活检、骨髓穿刺和活检以及体液检测。应根据适当情况和可行性进行GeneXpert MTB/RIF检测、线性探针分析、分枝杆菌培养和药敏试验。粟粒性肺结核的治疗应尽早开始，因为这可能挽救生命。对一线抗结核药物的反应良好。有必要对并发症如急性呼吸窘迫综合征（ARDS）进行筛查和监测，对药物不良反应如药物性肝损伤、药物相互作用进行监测，尤其是对合并艾滋病毒/艾滋病感染的患者。关于抗结核治疗的最佳方案和疗程，随机对照试验的数据稀少。
