A 78-year-old man was admitted due to recurrent fever and fatigue for past one year. Two weeks prior to admission, his fatigue intensified, and the highest temperature reached 39.5C. He had lost 5kg over the past year and had a history of cerebral infarction and hypertension. On examination, the patient was febrile at 38C. His C-reactive protein (CRP) (62.49 mg/dl), procalcitonin (0.213ng/mL) and erythrocyte sedimentation rate (84 mm/h) were elevated. Computed tomography (CT) of the chest revealed diffusely distributed nodules in both lungs, bilateral bronchiolitis, and tuberculosis could not be excluded. The aortic arch was thickened and the local calcified plaque moved inward, which indicated further aortic computed tomography angiography (CTA) examination (Figure 1). Echocardiography revealed no vegetation in the mitral and aortic valve areas. The chest CTA confirmed multiple atherosclerosis and ulcers, and intermural hematoma in the aortic arch and thoracic aorta. Combined with the medical history, the involvement of tuberculosis in the aorta should be highly suspected (Figure 2). Re-examination of lung CT revealed bronchiole lesions and multiple miliary foci in both lungs, which were larger than one week prior, with pleural effusion, and slightly thickened pleura, suggestive of miliary tuberculosis (Figure 3). The T cell spot test, sputum culture, and sputum GeneXpert test were positive for Mycobacterium tuberculosis and GeneXpert indicated sensitivity to rifampicin. Since disseminated tuberculosis was definite and the patient's disease potentially involved the major thoracic vessels, anti-tuberculosis and steroids were initiated immediately. Methylprednisolone was administered at 40mg/day for 3 days, 20mg/day for 3 days, 8mg/day for 3 days, 4mg/day for 7 days, and then discontinued. Due to liver dysfunction, with alanine aminotransferase of 161U/L and aspartate aminotransferase of 203U/L, a regimen consisting of meropenem 1 g every 8 h, linezolid 0.6 g once daily, amikacin 0.4 g once daily, and levofloxacin 0.5 g once daily was administered. Surgical consultation concluded that no immediate surgical intervention was needed because the aortic wall was not ruptured. On normalisation of liver function, the anti-tuberculosis regimen was changed to isoniazid 0.3 g once daily, rifapentine 0.45 g twice a week, linezolid 0.6 g once daily, ethambutol 0.75 g once daily, levofloxacin 0.5 g once daily. After two weeks of treatment, the patient's body temperature returned to normal, and a re-examination of the lung CT indicated that the lesion was partially absorbed (Figure 4). The patient was discharged and continued to receive oral medications. We planned the follow-up to be weekly initially, gradually transitioning to every two weeks, and then monthly after stabilisation. Routine blood, liver and kidney functions were examined at each follow-up visit. Sputum smears and cultures were performed monthly. Pulmonary CT was re-examined two months later, and aortic CTA was re-examined four months later. The patient tolerated and was compliant with anti-tuberculosis drugs.
Chest CT showing: bronchiole lesions and multiple miliary foci in both lungs with pleural effusion and slightly thickened pleura. This combined with the medical history is consistent with the diagnosis of hematogenous disseminated pulmonary tuberculosis.