Fatal Miliary Tuberculosis in a Young Woman With SLE on Immunosuppressive Therapy

Introduction: Miliary tuberculosis (TB) is a rare, disseminated form of Mycobacterium tuberculosis infection characterized by hematogenous spread of tubercle bacilli to multiple organs. It often presents with nonspecific symptoms but can lead to fulminant respiratory failure in immunocompromised patients. We present a case of a young woman with systemic lupus erythematosus (SLE) on combination immunosuppressive therapy who developed rapidly progressive miliary TB with diffuse alveolar hemorrhage (DAH), requiring extracorporeal membrane oxygenation (ECMO).


Description: A 28-year-old woman with SLE, complicated by Class IV lupus nephritis, presented with progressive dyspnea and chest pain for three weeks. She was admitted to the ICU with severe hypoxemia, metabolic acidosis, acute kidney injury, NSTEMI, shock liver, and pancytopenia. CT chest showed diffuse micronodules and patchy bilateral opacities. Bronchoscopy revealed friable mucosa with blood-tinged lavage, concerning for DAH. Worsening respiratory distress on NIPPV led to intubation. Overnight, bilateral pneumothoraces developed, requiring emergent chest tubes. Plasmapheresis was initiated given concern for lupus flare, along with broad-spectrum antimicrobials for possible infection. She recently started belimumab and voclosporin following renal biopsy, in addition to chronic prednisone, hydroxychloroquine, and mycophenolate mofetil. The patient remained severely hypoxic, saturating in the 70s, prompting ECMO. Microbiologic studies revealed acid-fast bacilli consistent with TB infection, and treatment was promptly initiated. Despite aggressive management, the patient died from massive pulmonary hemorrhage. A review of records and discussion with family later confirmed initiation of belimumab via manufacturer samples without recommended TB screening.


Discussion: This case underscores the critical importance of screening for opportunistic infections, particularly TB, before initiating immunosuppressive therapy. The combination of mycophenolate mofetil, steroids, and belimumab likely led to reactivation of latent TB. In critically ill patients, miliary TB may mimic autoimmune pulmonary manifestations, delaying diagnosis and treatment. Early suspicion, prompt diagnostic workup, and preventative screening are essential to avoid catastrophic outcomes.