(832) Miliary Tuberculosis in a Toddler Complicated by Intracardiac Thrombus and Intracranial Tuberculomas

Introduction: Miliary tuberculosis (TB) results from the hematogenous spread of Mycobacterium tuberculosis and is a relatively common complication of tuberculosis in children. The liver, central nervous system, lymphatic system, bones/joints, and adrenal glands are commonly affected organ systems. Inflammatory processes, such as infection, can lead to a hypercoagulable state, predisposing to thrombus formation. There are several reports of ischemic stroke and one report of internal jugular vein thrombus associated with miliary TB. We present a case of miliary TB with pulmonary vein thrombus and intracranial tuberculomas.

Description: A 2-year-old previously healthy female was admitted with 2 weeks of respiratory distress, malaise, and decreased oral intake. Chest radiograph showed diffuse small bilateral pulmonary nodules, and she was started on antibiotics for atypical pneumonia. On hospital day 2, she required escalating respiratory support and was transferred to the ICU where she was intubated for severe ARDS. Extensive infectious disease workup was performed, and she was treated with broad-spectrum antibiotics. Echocardiography revealed a 19 mm x 1 mm x 2.6 mm thrombus in the left pulmonary vein extending into the left atrium, and she was started on parenteral anticoagulation. Brain imaging on hospital day 4 showed diffuse hyperintense enhancing lesions, suggesting septic emboli. Bronchoscopy was performed on hospital day 6, which revealed the diagnosis of tuberculosis by PCR. She was started on rifampin, isoniazid, pyrazinamide, and ethambutol as well as prednisone due to CNS involvement. She clinically improved and was extubated on hospital day 15. She was ultimately discharged home on hospital day 33. Hypercoagulable workup thus far is negative, and immunologic evaluations are ongoing.

Discussion: Miliary TB is a relatively common complication of tuberculosis in children. It can have devastating effects on the CNS, including meningitis, tuberculomas, and septic emboli. There are no known reports of intracardiac thrombi associated with tuberculosis. We suggest further investigation into tuberculosis as part of a broad infectious workup for septic intracardiac thrombi when routine cultures are sterile.