In this report 21 patients in whom
tuberculosis was the primary cause of death, but which was not diagnosed until necropsy, are reviewed. Of the 21 deaths, 11 were due to
pulmonary tuberculosis and 10 to
miliary tuberculosis. Proper evaluation of the following factors might have led to the correct diagnosis in many of the patients: A family history of
tuberculosis, prior
pleurisy, a
gastrectomy,
diabetes mellitus or
end-stage renal failure; all can be associated with an increased incidence of
tuberculosis. A negative
tuberculin skin reaction does not exclude the presence of active
tuberculosis. In the search for Mycobacterium tuberculosis, the examination of just one or two sputum specimens is not an adequate bacteriologic investigation. A positive gastric smear can have diagnostic importance. Ascitic fluid findings can be characteristic of
tuberculous peritonitis. A negative bone marrow aspirate for
acid-fast bacilli does not exclude
miliary tuberculosis. Significant
anemia, high
fever and
leukopenia increases the possibility of
tuberculosis. The persistence and/or progression of lung infiltration, irrespective of supposedly specific
antibiotic therapy, strongly suggests
tuberculosis.
Miliary tuberculosis can present as an
adult respiratory distress syndrome. All but one patient in this series had
fever. the failure to diminish the
pyrexia believed due to specific lung
infections with presumably effective
antibiotics, and the inability of
therapy to control other conditions thought to cause the
fever indicate the presence of
tuberculosis.
Tuberculosis, especially miliary disease, should be considered as a possible etiology of
fever of unknown origin. If the diagnosis of
tuberculosis is highly suggestive, even without bacteriologic confirmation, a therapeutic trial of antituberculosis drugs should be given.