A case of miliary tuberculosis showing diffuse alveolar hemorrhage

: A 43-year-old diabetic man had a productive cough and high fever and was admitted to another hospital. His condition did not improve despite treatment with Cefepime, and he was transferred to our hospital. Chest X-ray films and CT findings showed pulmonary infiltration and diffuse ground-glass opacities in bilateral lung fields, but disseminated nodules were not identified. Since his bronchial lavage fluid (BALF) was bloody, we suspected diffuse alveolar hemorrhage due to vasculitis. Steroid pulse therapy was given, and his fever and chest X-ray findings completely improved. However, 1 week later, he again suffered a high fever and bloody sputum, and a chest X-ray film showed granular shadows in bilateral lung fields. He died of respiratory failure on the 18th hospital day despite treatment and mechanical ventilation. An autopsy revealed many necrotizing epithelioid granulomas in both lungs, the liver, the spleen, both kidneys and both adrenal glands. These findings indicated miliary tuberculosis, and a culture of his sputum and BALF finally revealed mycobacterium tuberculosis. Marked alveolar hemorrhage and a hyaline membrane were also found in both lungs, but vasculitis was not recognized in any organ. We report this case, because to the best of our knowledge diffuse alveolar hemorrhage has not been reported as the primary symptom of miliary tuberculosis.