Case Presentation: We present a case of a 77 year old Filipino male with Chronic Kidney Disease Stage 5, Diabetes Type 2, stage I diastolic congestive heart failure and hypertension who presented with dyspnea and abdominal pain in the setting of paradoxical hypercalcemia. On CT chest, the patient had unremarkable lung parenchyma with a large right-sided pleural effusion, which was exudative and acid fast bacilli negative. With a normal serum angiotensin converting enzyme without any notable lymphadenopathy and a polyclonal serum protein electrophoresis, sarcoid and multiple myeloma were respectively ruled out. During the hospitalization, the patient’s Quantiferon Gold returned positive. The patient subsequently underwent a pleural biopsy, which was also acid fast bacilli negative. While the initial culture of the pleural biopsy was acid fast bacilli negative, histopathology revealed necrotizing and non-necrotizing granulomas, more consistent with an inflammatory process than tuberculosis as per pathology. A fat pad biopsy was performed, which was negative for amyloidosis. Shortly thereafter, the patient developed significant right knee pain and swelling, after which he had undergone joint aspiration, which was acid fast bacilli and crystal negative twice. With worsening abdominal pain, a CT abdomen was performed, which revealed a necrotic terminal ileal mass. A colonoscopic biopsy of the mass was performed, which demonstrated granulation tissue with “fish scale” crystals, consistent with sevelamer-associated enteritis. The initial acid fast bacillus stain of the terminal ileal biopsy was negative. The patient was discharged without tuberculosis treatment, as there was no evidence of caseating granulomatous disease in the lung, knee, or terminal ileum. After two to three weeks of culture, the cultures of the pleural and terminal ileal biopsies along with the joint aspirate were positive for pan-sensitive Mycobacterium Tuberculosis. The Department of Health was notified and the patient was started on Rifampin, Isoniazid, Pyrazinamide, and Ethambutol with continued outpatient follow up.
Discussion: To our knowledge, this is the first report of a case of disseminated extrapulmonary tuberculosis in a patient without underlying autoimmune or hematologic malignancy. In 2008, Neonakis and colleagues reported a case of a 64 year old male with myelodysplastic syndrome who presented with fever and fatigue, initially attributed to a myelodysplastic flare. With negative imaging and serology studies, a bone marrow biopsy was performed, which revealed caseating granulomas, later confirmed extrapulmonary miliary tuberculosis. In 2014, Yamashita and colleagues described a case of a 48 year old female with systemic lupus erythematosus and autoimmune hepatitis who was initially hospitalized and treated for an autoimmune hepatitis flare which did not respond to pulse steroid therapy. After subsequent liver biopsy, the patient was found to have miliary tuberculosis without pulmonary involvement with the main focus being the liver. Similarly to these patients, the patient in our presentation did not have any obvious radiographic or serologic evidence only to later be diagnosed with miliary tuberculosis without pulmonary involvement after sufficient time was allowed for culture growth and speciation.
Conclusions: Tuberculosis has evolved to pantomime the presentation of a variety of infectious, rheumatologic, and oncologic diseases, and as such, should be ruled out if there is any clinical suspicion.