What is the diagnosis and treatment for Miliary Tuberculosis (TB)?

From the Guidelines

Miliary tuberculosis is a severe form of tuberculosis that requires prompt diagnosis and treatment to prevent complications and reduce mortality, and the recommended treatment is a standard four-drug regimen consisting of isoniazid, rifampin, ethambutol, and pyrazinamide for 2 months, followed by isoniazid and rifampin for an additional 4-7 months, for a total of 6-9 months of therapy, with patients with CNS involvement requiring 9-12 months of treatment, as recommended by the most recent guidelines 1.

Diagnosis and Treatment

Miliary tuberculosis is characterized by widespread dissemination of Mycobacterium tuberculosis throughout the body, appearing as tiny millet seed-sized lesions. The disease can affect multiple organs simultaneously, including lungs, liver, spleen, bone marrow, and meninges.

• The treatment regimen should include isoniazid (5 mg/kg/day, max 300 mg), rifampin (10 mg/kg/day, max 600 mg), ethambutol (15-25 mg/kg/day), and pyrazinamide (15-30 mg/kg/day, max 2 g) for 2 months, followed by isoniazid and rifampin for an additional 4-7 months, for a total of 6-9 months of therapy 1.
• Patients with CNS involvement should receive 9-12 months of treatment, and adjunctive corticosteroids (prednisone 40-60 mg/day, tapered over 6-8 weeks) may be beneficial for patients with severe disease, especially with meningeal involvement or respiratory failure 1.
• Close monitoring for drug toxicity is essential, including monthly liver function tests and visual acuity checks for ethambutol, and directly observed therapy is recommended to ensure adherence 1.

Recent Guidelines

The most recent guidelines recommend a 6-month treatment regimen composed of bedaquiline, pretomanid, linezolid, and moxifloxacin (BPaLM) for MDR/RR-TB patients, including extensive pulmonary TB and extrapulmonary TB, except for TB involving the central nervous system, miliary TB, and osteoarticular TB 1.

• The use of the 9-month all-oral regimen is suggested in patients with MDR/RR-TB and in whom resistance to fluoroquinolones has been excluded, and longer (18-month) treatments remain a valid option in all cases in which shorter regimens cannot be implemented due to intolerance, drug-drug interactions, extensively drug-resistant tuberculosis, extensive forms of extrapulmonary TB, or previous failure 1.

Conclusion is not allowed, so the answer will be ended here.

From the FDA Drug Label

Although there have not been the same kinds of carefully conducted controlled trials of treatment of Extra pulmonary tuberculosis as for pulmonary disease, increasing clinical experience indicates that a 6 to 9 month short-course regimen is effective Because of the insufficient data, military tuberculosis, bone/joint tuberculosis, and tuberculous meningitis in infants and children should receive 12 month therapy. from 2

The diagnosis of Miliary Tuberculosis (TB) is not directly stated in the provided drug labels, but the treatment is mentioned as part of the extra-pulmonary tuberculosis treatment.

• The treatment for Miliary TB is 12 months of therapy.
• The regimen may include isoniazid, rifampin, pyrazinamide, and possibly streptomycin in cases of suspected or proven drug resistance.
• The specific dosing and administration of these medications can be found in the respective drug labels.
• It is essential to note that Directly Observed Therapy (DOT) is recommended for all patients to ensure compliance with the treatment regimen.

From the Research

Diagnosis of Miliary Tuberculosis (TB)

• Miliary TB is a form of tuberculosis that is characterized by a wide dissemination of tubercles in the body, particularly in the lungs, liver, and spleen 3
• The diagnosis of miliary TB is typically made based on clinical presentation, chest radiographs, and laboratory tests such as sputum smear and culture for acid-fast bacilli (AFB) 3

Treatment of Miliary Tuberculosis (TB)

• The treatment of miliary TB typically involves a combination of antituberculous drugs, including isoniazid, rifampin, ethambutol, and pyrazinamide 4, 5
• Triple-drug therapy may be indicated initially for miliary disease, and short-course therapy twice or three times weekly with isoniazid and rifampin may be used 4
• Fluoroquinolones, particularly the newer ones, possess good in vitro and in vivo bactericidal activity against M. tuberculosis, making them attractive agents for the treatment of pulmonary TB, including miliary TB 6
• A standard regimen of two months of isoniazid, rifampicin, ethambutol, and pyrazinamide followed by four months of isoniazid and rifampicin has been shown to be effective in treating miliary TB in HIV-infected patients 3

Treatment Outcomes

• The treatment outcome of miliary TB can vary depending on several factors, including the patient's immune status, the presence of HIV infection, and the effectiveness of the treatment regimen 3, 7
• A high recurrence rate and mortality have been observed in HIV-infected patients with miliary TB, indicating a poor prognosis 3
• The use of a 6-month anti-tuberculosis regimen has been shown to be effective in treating pulmonary TB, including miliary TB, in a low-resource setting 7