SHM Converge Scientific Abstract ePoster Gallery-When Evidence Eludes: Trusting Clinical Instincts in Tuberculosis

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This case describes a 36-year-old man from Haiti who presented with four months of fever, dry cough, night sweats, and weight loss. He was febrile and tachycardic, with mild normocytic anemia and elevated CRP. Chest imaging showed a classic miliary tuberculosis pattern with hilar lymphadenopathy, creating a high pretest probability for TB.<br /><br />Despite the strongly suggestive clinical and radiographic picture, the initial TB workup was negative. Transbronchial biopsy revealed non-caseating granulomas, which led clinicians to consider sarcoidosis and start high-dose steroids. However, the patient continued to worsen, developing cytopenias, transaminitis, and marked hyperferritinemia. Secondary hemophagocytic lymphohistiocytosis (HLH) was confirmed by bone marrow biopsy and elevated inflammatory markers, and he was treated with etoposide and steroids.<br /><br />As his condition deteriorated further into respiratory failure and multiorgan dysfunction, repeat infectious testing was performed. Next-generation sequencing (Karius) detected TB, and repeat bronchoalveolar lavage testing later became positive by AFB, MTB-PCR, and culture. RIPE therapy was started, but unfortunately the patient ultimately died.<br /><br />The key teaching point is that tuberculosis diagnostic tests have imperfect sensitivity, especially in miliary disease. Non-caseating granulomas do not exclude TB, and results must be interpreted in the context of epidemiologic risk, symptoms, and imaging. In high-risk patients, clinicians should consider empiric treatment for TB even when initial testing is negative, because delaying therapy can lead to severe complications and death.

Asset Subtitle

Prachi Mann

Meta Tag

Author List Alexa Constantakos, Dwayne Gordon, Edward Maharam, George Everett, Ivonne De La Hoz, Prachi Mann

Category Clinical Vignettes

Concept Tuberculosis

Concept Miliary Tuberculosis

Concept Secondary hemophagocytic lymphohistiocytosis

Concept Diagnostic Test Sensitivity

Concept Pre-test Probability

Distinguished Non-Finalist

Presenter Organization Adventhealth Orlando

Presenting Author Prachi Mann

Track Adult

Keywords

miliary tuberculosis

non-caseating granulomas

sarcoidosis

hemophagocytic lymphohistiocytosis

HLH

next-generation sequencing

Karius test

RIPE therapy

bronchoalveolar lavage

AFB culture

Tuberculosis

Miliary Tuberculosis

Secondary hemophagocytic lymphohistiocytosis

Diagnostic Test Sensitivity

Pre-test Probability