A 47-year-old male presented to the pulmonology outpatient clinic for the cough that had lasted for two months. At that time, he complained of general weakness, dyspnea and sweating as well as a weight loss of 10 kg that occurred over a four-month period. There was no specific past history but crackles in the right lung were evident in the physical examination. Numerous disseminated nodules in both lung fields were found in a chest x-ray. Chest computed tomography (CT) revealed a variety of small disseminated nodules in both lungs and mediastinal lymph node. Sputum was tested on suspicion of miliary TB. Test for Mycobacterium tuberculosis (M. tuberculosis) complex was positive. He was admitted into an isolation ward and treated with empirical anti-TB agents (isoniazid 400 mg, ethambutol 1,200 mg, rifampicin 600 mg).
In the seventh day after admission, he complained of the sudden hearing loss and tinnitus in his right ear that had begun that morning. He was referred to Otorhinolaryngology (ENT) consultation for diagnosis and treatment. In addition to a decrease in hearing, there were no other neurological symptoms and vestibular symptoms. Pure-tone audiometry was normal in the left ear, while both bone and air conduction threshold in the right ear were unresponsive (Fig. 1A). Unilateral sensorineural hearing loss was evident. Other hearing evaluations such as auditory brainstem response, otoacoustic emission did not proceed. Brain T1-weighted axial magnetic resonance imaging revealed multiple nodules 1-4 mm in size with high signal intensity randomly distributed around the cerebral subcortex, pons, and cerebellum (Fig. 2A). T1-weighted coronal images showed high signal distributed by vestibulocochlear area and some parts of semicircular canal area (Fig. 2B). According to radiologic findings, we diagnosed the patient as miliary TB with brain and labyrinth invasion. Pyrazinamide was added along with existing anti-TB agents and high-dose steroid therapy (10-day course prednisone 60 mg with taper) was started. Two months later, the multiple nodules were no longer found in the brain CT (Fig. 2C). Anti-TB agents were maintained for 12 months. However, both bone and air conduction threshold in the right ear was not improved (Fig. 1B).