Background: A miliary pattern on chest imaging is often attributed to tuberculosis (TB) infection. However, a myriad of conditions can cause a miliary pattern, many of which are imminently life-threatening. Research Question: The primary aim of our study is to elucidate the potential causes of miliary chest imaging patterns to improve workup and empiric therapy selection. The secondary aims are to discern the predictors of miliary disease etiology and to determine whether appropriate empiric antimicrobial therapies were given. Study Design and Methods: In this retrospective cohort study, we searched a radiology database for patients with chest imaging studies described by the word \"miliary\". Subjects were excluded if they were under 18 years of age and if there were insufficient objective data to support a miliary disease etiology. A radiologist independently reviewed all imaging studies, and studies that did not appear to have a true miliary pattern were excluded. The collected data include patient demographics, immunocompromising risk factors, conditions associated with miliary disease, β-D-glucan levels, serum eosinophil count, and empiric therapies received. Results: From our 41-patient cohort, 22 patients (53.7%) were clinically diagnosed with coccidioidomycosis, 8 (19.5%) with TB, 7 (17.1%) with metastatic solid cancer, 1 (2.4%) with lymphoma, 1 (2.4%) with other (Mycobacterium simiae), and 3 (7.3%) with unknown diseases (the sum equals 42 patients because one individual was diagnosed with both coccidioidomycosis and TB). All six patients with greater than 500 eosinophils/μL were diagnosed with coccidioidomycosis. Of the 22 patients diagnosed with coccidioidomycosis, 20 (90.91%) were empirically treated with an antifungal regimen. Of the eight patients with TB, six were empirically treated for TB. Interpretation: Based on our data from a Coccidioides-endemic region with close proximity to tuberculosis-endemic areas, the leading cause of miliary disease is coccidioidomycosis, although TB and cancer are also common etiologies. Serum eosinophilia and elevated β-D-glucan levels were strongly predictive of coccidioidomycosis in our patient cohort with a miliary chest imaging pattern.

BACKGROUND: Despite effective treatments, tuberculosis-related mortality remains high among patients requiring admission to the intensive care unit (ICU).
OBJECTIVE: To determine prognostic factors of death in tuberculosis patients admitted to the ICU, and to develop a simple predictive scoring system.
METHODS: A 10-year, retrospective study of 53 patients admitted consecutively to the Hôpitaux de Paris, Hôpital Lariboisière (Paris, France) ICU with confirmed tuberculosis, was conducted. A multivariate analysis was performed to identify risk factors for death. A predictive fatality score was determined.
RESULTS: Diagnoses included pulmonary tuberculosis (96%) and tuberculous encephalomeningitis (26%). Patients required mechanical ventilation (45%) and vasopressor infusion (28%) on admission. Twenty patients (38%) died, related to direct tuberculosis-induced organ failure (n=5), pulmonary bacterial coinfections (n=14) and pulmonary embolism (n=1). Using a multivariate analysis, three independent factors on ICU admission were predictive of fatality: miliary pulmonary tuberculosis (OR 9.04 [95% CI 1.25 to 65.30]), mechanical ventilation (OR 11.36 [95% CI 1.55 to 83.48]) and vasopressor requirement (OR 8.45 [95% CI 1.29 to 55.18]). A score generated by summing these three independent variables was effective at predicting fatality with an area under the ROC curve of 0.92 (95% CI 0.85 to 0.98).
CONCLUSIONS: Fatalities remain high in patients admitted to the ICU with tuberculosis. Miliary pulmonary tuberculosis, mechanical ventilation and vasopressor requirement on admission were predictive of death.
Malgré des traitements efficaces, la mortalité liée à la tuberculose demeure élevée chez les patients qui doivent être hospitalisés à l’unité de soins intensifs (USI).
Déterminer les facteurs pronostiques de décès chez les patients tuberculeux admis à l’USI et élaborer un système d’indice prédictif simple.
Les chercheurs ont mené une étude rétrospective d’une durée de dix ans auprès de 53 patients hospitalisés consécutivement à l’USI de l’Hôpital Lariboisière des Hôpitaux de Paris, en France, en raison d’une tuberculose confirmée. Ils ont procédé à une analyse multivariée pour déterminer les facteurs de risque de décès et ont établi un indice prédictif de fatalité.
Les diagnostics incluaient une tuberculose pulmonaire (96 %) et une encéphaloméningite tuberculeuse (26 %). Les patients avaient besoin d’une ventilation mécanique (45 %) et d’une perfusion de vasopresseur (28 %) à l’admission. Vingt patients (38 %) sont décédés en raison d’une insuffisance organique liée directement à la tuberculose (n=5), de co-infections bactériennes pulmonaires (n=14) et d’une embolie pulmonaire (n=1). Selon l’analyse multivariée, trois facteurs indépendants à l’admission à l’USI étaient prédictifs d’une fatalité : une tuberculose miliaire (RRR 9,04 [95 % IC 1,25 à 65,30]), une ventilation mécanique (RRR 11,36 [95 % IC 1,55 à 83,48]) et des besoins vasopressifs (RRR 8,45 [95 % IC 1,29 à 55,18]). Un indice conforme à la somme de ces trois variables indépendantes était efficace pour prévenir la fatalité, avec une zone sous la courbe ROC de 0,92 (95 % IC 0,85 à 0,98).
Les décès demeurent élevés chez les patients tuberculeux admis à l’USI. La tuberculose miliaire, la ventilation mécanique et les besoins vasopressifs à l’admission sont prédictifs d’un décès.