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Image 24 A 77 year old from Laos in Canada for 19 years presented with chills and fever for a week. Investigation revealed a negative blood culture, normal hematology, slightly raised liver enzymes and a normal chest x-ray. For 3 more weeks she continued with a low grade fever, fatigue, anorexia, weight loss, some dyspnoea and finally fainting on the day before admission with this chest x-ray. A sputum induction, a bronchoalveolar lavage (BAL) and a transbronchial biopsy were negative for acid fast bacilli. The diagnosis is:

Image 24

Image 24. This was miliary TB until proven otherwise. In miliary TB sensitivity of the acid fast stain for AFB in sputum, BAL and transbronchial biopsy is poor (ref: Mert A et al. Respirology 2001: 6; 217-224) In our case the biopsy was the earliest clue (reported on day 3 as necrotizing granulomas). The day 2 post BAL sputum grew Mycobacteria in 20 days, the BAL material grew at 27 days, and the biopsy yielded no growth. Interestingly there is evidence that a post-BAL sputum yields more AFB than a BAL (Manual of Clinical Microbiology eds. Murray PR et al 1995).