D
FIGURES D and E
Intracranial computed tomography angiography showing numerous central nervous system tuberculomas .
E medication compliance . Patients residing in rural Appalachia are more likely to experience barriers to healthcare access that can be prohibitive to effective therapy completion . In a study by Wallace et al , TB patients from Appalachian states were more likely to complete therapy within one year if they were managed by health departments than if they were only followed by their primary care provider . 2 Additionally , the overall effect of health department involvement on TB treatment compliance was higher in Appalachian residents than in non-Appalachian patients . 2 This finding highlights the importance of establishing communication with state health departments as well as ensuring adequate outpatient follow up for these high risk patients .
DISCUSSION
In recent years , the rate of diagnosed primary or reactivated TB in the United States ( US ) has gradually declined , reaching 2.7 cases per 100,000 persons in 2019 . 1 WV has a considerably lower rate of TB ( 0.6 cases per 100,000 persons ) compared to the remaining Appalachian region . 2 Although Appalachian TB rates are similar to the rural non-Appalachian US , it is important to note the risk of under-recognized and therefore undertreated TB secondary to poor access to healthcare in this region . 2
Miliary TB can develop either at the time of primary infection or later , during reactivation of a dormant focus . 3 Accounting for only 3 % of incident TB cases in the US , mortality from it is estimated at 25- 30 %. 4 Tuberculosis can involve essentially any organ system , with most frequent extra-pulmonary sites involving lymph nodes , pleura , and osteoarticular areas . 5 In cases of intestinal involvement , TB can have macroscopic granulomatous lesions similar in distribution to CD , making it difficult to distinguish endoscopically . 6 , 7 Therefore , it is essential to differentiate TB from granulomatous Crohn ’ s colitis because initiation of immunosuppressant therapy in a patient with TB can lead to dissemination as illustrated in this case . 5 Screening for TB is mandatory in all CD patients prior to initiation of treatment with anti-tumor necrosis factor-alpha inhibitors or other biologic therapy . 8 However , patients without
identifiable risk factors are not screened for TB as strictly prior to starting other immunosuppressant therapies such as sulfasalazine , as in our patient . 8
Commonly encountered risk factors for disseminated TB include use of immunosuppressant medications , particularly biologic agents and chemotherapy , infection with human immunodeficiency virus , and extremes of age . 4 Importantly , corticosteroids are associated with increased risk for disseminated TB . 7 Prednisone is an extremely common medication used for various conditions , but doses as low as 15 mg per day for a duration longer than two to four weeks have been associated with increased risk for TB . 9 However , these patients do not typically undergo TB screening prior to or during steroid therapy . 9 In a study by Rosenthal et al , 10 32.4 % of the patients with disseminated TB received steroids during the course of their disease . It is therefore imperative to consider TB as a potential diagnosis , even in patients without obvious risk factors or exposure history . Of note , despite high dose corticosteroid use being a recognized risk factor , steroids also have been used for adjuvant TB treatment in some cases . Predominately , corticosteroids are utilized for tuberculous meningitis or pericarditis , refractory hypoxemia , and immune complex nephritis secondary to TB . 5
Once diagnosed , prompt initiation of antituberculosis therapy is vital , as is ensuring
CONCLUSION
Miliary TB is a potentially lethal condition that frequently mimics more commonly encountered diseases . Rates of diagnosed tuberculosis have generally been lower in WV compared to the remaining Appalachian region and the greater US . The reason for the lower rate is WV is unknown , and physicians may be less inclined to include TB in differential diagnoses . Clinicians must consider that apparent risk factors for TB may not always be present . Even in cases without definitive exposure history such as described in this case , it remains essential to maintain a high index of clinical suspicion for prompt diagnosis and therapy initiation . Anti-tuberculosis therapy must involve both the patient ’ s primary care physician and the state health department to achieve higher rates of medication compliance and better outcomes .
REFERENCES
1 . Schwartz NG , Price SF , Pratt RH , Langer AJ . Tuberculosis — United States , 2019 . MMWR Morb Mortal Wkly Rep 2020 ; 69 ( 11 ): 286-89 .
2 . Wallace R , Armstrong L , Pratt R , Kammerer S , Iademarco M . Trends in tuberculosis reported from the Appalachian region : United States , 1993- 2005 . J Rural Health . 2008 ; 4:236-43 .
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