Miliary Tuberculosis Presenting as Septic Shock

A 95 year old woman was brought to emergency department (ED) by fire rescue with mental status change, fever, and hypotension. In ED, the patient was unresponsive to verbal and painful stimuli. She was intubated for airway protection. Physical examination revealed blood pressure of 83/42 mmHg, Heart rate of 125breath/min, and temperature of 102°F. Chest auscultation was significant for bilateral diffuse crackles. Laboratory finding were: white blood cell count of 8.0 x 103, hemoglobin of 14.6 gm/dl, platelet of 121,000, creatinine 1.4 mg/dl, albumin of 2.3 gm/dl, and mildly elevated aminotransferases. Computed tomography (CT) scan of chest showed bilateral diffuse nodular lesions (Figure1). The patient was treated with fluid resuscitation, wide spectrum antibiotics, and vasopressor medication. The patient developed refractory shock and multiorgan failure. Two sets of blood culture were negative. Unfortunately the patient died shortly after admission to intensive care unit. At autopsy, lung exa