A 22-year-old male patient presented to the emergency department with complaints of gradually progressive breathlessness for three months, which had increased significantly over the last 10 days, dry cough, fever, vomiting, and loss of appetite. The patient also reported chronic complaints of left-sided chest pain and weight loss for eight months. Given his worsening oxygenation situation, the patient was admitted to the intensive care unit and started on non-invasive ventilation with oxygen support.
On obtaining the patient's detailed history, it was revealed that he was well eight months ago before he developed left-sided chest pain, which varied in intensity, and was admitted to a private hospital, where a chest radiograph was conducted and revealed left-sided moderate pleural effusion. Therapeutic thoracentesis was done, and approximately 1000 mL of hemorrhagic pleural fluid was drained. Pleural fluid cytology revealed a lymphocyte-predominant pleural fluid with high cellularity, but no evidence of malignancy was reported by the cytopathologist. The patient had no history of comorbid conditions apart from chronic alcohol consumption for four years.
On general examination, his findings were as follows: pulse rate: 128 beats/minute; respiratory rate: 28 breaths/minute; blood pressure: 90/50 mm Hg; and oxygen saturation (SpO2 %): 88% on room air. Pallor was present, while icterus was absent, and chest auscultation revealed the presence of bilateral crepitations.
A chest X-ray with a posteroanterior (PA) view was done on admission and revealed bilateral miliary opacities with symmetrical distribution (Figure 1).
For further evaluation of the abnormal chest X-ray findings, a contrast-enhanced computerized tomography (CT) scan of the thorax was performed, revealing the presence of multiple centrilobular nodules arranged in random distribution with tree-in-bud appearance and lymphadenopathy. The left upper lobe showed consolidation with focal changes of bronchiectasis, and these CT features were suggestive of miliary TB (Figure 2).
For further evaluation, a flexible fiber optic bronchoscopy was done, which showed the presence of thick mucopurulent secretions present in the left bronchial tree. No visible endobronchial mass or anatomical abnormality was observed.
The reports of various other investigations done for the patient are summarized in Table 1.
After starting non-invasive ventilation (NIV) support and anti-tubercular therapy (ATT), the patient started to show improvement in the oxygenation status and blood parameters and was gradually weaned from oxygen support and shifted to the general ward. 
The patient was discharged after 21 days on ATT with a standard four-drug regimen of Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), and Ethambutol (E), which are to be continued for six months. The patient was asked for a follow-up after seven days but was lost to the follow-up. This loss was probably a result of the considerable geographical distance between the patient's hometown and our hospital. Hence, no follow-up radiological investigations could be conducted to assess improvements. A differential diagnosis of malignancy was ruled out through a cytological analysis of the pleural fluid and the bronchoalveolar lavage fluid for malignant cells. A proper history ruled out other etiologies such as occupational lung diseases and hypersensitivity pneumonitis.