# Delayed Pulmonary Manifestations of Miliary Tuberculosis Following a Normal Initial High-Resolution Computed Tomography

## TL;DR

An elderly woman with miliary tuberculosis initially showed no signs on a CT scan, but was later diagnosed after symptoms and tests confirmed the disease.

## Contribution

This case emphasizes the need to consider miliary TB in persistent fever cases, even with normal initial imaging.

## Key findings

- Initial HRCT and microbiological tests showed no abnormalities in the patient.
- Delayed miliary infiltrates on repeated HRCT and positive IGRA led to a definitive diagnosis.
- Minimally invasive procedures helped confirm the diagnosis and guide treatment.

## Abstract

Miliary tuberculosis (TB) is a potentially fatal form of TB resulting from the widespread dissemination of Mycobacterium tuberculosis. Although the presence of pulmonary miliary infiltrates usually facilitates diagnosis, atypical cases lacking these characteristic imaging findings frequently confound clinicians. Here, we describe the case of an 82-year-oldJapanese woman with miliary TB who initially presented with fever but showed no abnormalities on high-resolution computed tomography (HRCT) and microbiological tests; hence, fever of unknown origin was diagnosed. The delayed appearance of miliary infiltrates on repeated HRCT and positive interferon-gamma release assay (IGRA) led to a definitive diagnosis through bone marrow aspiration, bronchoalveolar lavage, and blood cultures. This case highlights the importance of miliary TB as a differential diagnosis for persistent fever, although initial imaging studies showed no abnormalities. Additionally, we discuss the value of repeated HRCT, IGRA, and minimally invasive diagnostic procedures for the early detection and timely treatment of miliary TB.