TB Or Not TB

A 15-yr-old girl came to the ED after 9 days of fever, night sweats, and productive cough that did not improve with antibiotics.  She had been very healthy with no significant illnesses, so we were all shocked to see her CXR which revealed an astounding plethora of tiny pulmonary nodules.  A chest CT also showed multiple tiny pulmonary nodules, along with a 1 cm cavitary lesion, which the pulmonologist in Anchorage agreed was highly suspicious for miliary tuberculosis which is disseminated hematogenously.  Other conditions on the differential diagnosis included collagen vascular disease and neoplasm.  Per protocol, I alerted the authorities (in this case, Alaska State Public Health and the office of Infection Control at the hospital) and started our patient on the potent 4-drug tuberculosis regimen.  Two days later, her PPD was looking extremely positive, with a raised erythematous induration of 25 mm.