A 28-year-old female gravid- 2 Para- 1 with an uneventful antenatal period delivered a full-term female child weighing 2.5 Kg by normal vaginal delivery. She developed intermittent high-grade fever associated with chills one week after delivery. There were no other complaints. There was no significant past history of illness or contact with a case of tuberculosis. General physical examination revealed pallor. There were no enlarged lymph nodes or palpable liver and spleen. The lungs were clinically normal. Initial laboratory investigations were as follows: haemoglobin-8.3 gm/dL, MCV-96.5 fl, MCH-28.2 pg, and MCHC-29.2 g/dL, total leucocyte count was 7,500/cumm with 57% polymorphs and 30% lymphocytes. Erythrocyte sedimentation rate (Westergreen) was 45 mm fall first hour. Liver and renal function tests were within normal limits. Widal test for enteric fever, strip test for malarial parasite, and urine and blood culture were not contributory. Serology for HIV, HBV, and HCV was negative. Chest radiography and ultrasound abdomen done during second week of fever were essentially normal.
Patient was initially treated as a case of viral fever and then empirically for enteric fever. She, however, continued to have low-grade fever with night sweats. Three weeks later follow-up ultrasound abdomen revealed mild hepatosplenomegaly. Repeat chest radiograph done at this stage was normal. Mantoux test and mycobacteriology serology panel for Anti-A60 Mycobacterium IgG, IgA, and IgM were negative. Patient was now put empirically on antimalarials but she continued to be symptomatic.
Chest radiograph repeated four weeks later suggested the presence of bilateral miliary mottling (Figure 1). The diagnosis of miliary tuberculosis was confirmed by high resolution CT scan (Figure 2). The patient was started on 4-drug regimen ATT (isoniazid, rifampicin, ethambutol, and pyrazinamide) for first three months, followed by isoniazid and rifampicin for next six months. In a few days there was significant improvement in general condition of the patient. She became afebrile after 10 days of ATT. Followup imaging study after 9 month of treatment revealed no residual activity. Newborn was vaccinated with BCG at birth. She was breast fed and put on INH prophylaxis for 3 months. She had a normal chest skiagram and negative Mantoux test before and after INH therapy. Both mother and child are doing fine after one year of follow-up.