ANSWER 20
This patient has fever, marked weight loss and a leucoerythroblastic anaemia. The length of
the symptoms makes infections such as malaria unlikely, although this should be checked
since she arrived from Nigeria and combined infections are possible. A very important
finding is that immature red and white cells are seen in the peripheral blood. This leuco-
erythroblastic anaemia indicates bone-marrow replacement by tumour or infection forcing
immature cells out into the blood. This woman has miliary tuberculosis. Miliary tubercu-
losis is characterized by tuberculous granulomata throughout the body due to widespread
dissemination of tubercle bacilli. It is now usually seen in elderly persons and the diagno-
sis is often only made at autopsy. The chest X-ray shows miliary lesions (multiple small
nodules 2–5 mm in diameter). These are often subtle or not visible at presentation. There
may be choroidal tubercles in the eyes on funduscopy and hepatosplenomegaly.
!
- Other infections: visceral abscesses, infective endocarditis, specific organisms (e.g.
brucellosis, actinomycosis or toxoplasmosis) and tropical diseases (e.g. malaria or
trypanosomiasis). - Neoplastic diseases: lymphomas, renal cell carcinomas, pancreatic tumours.
- Collagen vascular diseases, e.g. systemic vasculitis, rheumatoid arthritis, systemic
lupus erythematosus, temporal arteritis. - Miscellaneous: recurrent pulmonary emboli, drug fever, sarcoidosis.
Differential diagnoses of fevers!3 weeksThis patient needs an urgent diagnosis. Bronchoscopy with lavage may reveal acid-fast
bacilli. Biopsy of her liver and bone marrow may show tubercle bacilli or caseating gran-
ulomas. The tissue should also be sent for culture. The tuberculin test may be negative
because of immunoincompetence induced by the disease. Antituberculous treatment with
four agents must be started immediately once biopsy material has been obtained. In a
woman of child-bearing age a pregnancy test should be done, particularly in the face of
menstrual irregularities. In severely ill patients corticosteroids are of benefit. The total
lymphocyte count is low and, in a patient from Africa, HIV infection is a distinct possi-
bility. Informed consent should be sought for an HIV test. Tuberculosis is a notifiable dis-
ease and the diagnosis should be notified and arrangements made to screen her children
and any other close contacts.
Although eligibility for treatment needs to be assessed by appropriate managers, this
woman has an acute life-threatening illness and is a potential infective risk to others.
Investigation and treatment should be undertaken in the normal way.
- Miliary tuberculosis is often missed as a cause of weight loss and fever in the elderly.
- Miliary tuberculosis may present with a leucoerythroblastic anaemia.
- Always culture biopsy material in patients with pyrexias of unknown origin.