Acute Miliary Tuberculosis.
Synonyms:—Acute tuberculosis; acute phthisis; galloping consumption.
Definition:—A condition in which there is general infection of the whole body by the bacillus tuberculosis, resulting in the development of tubercules in a number of organs, or throughout the tissues of the body—a scattered tubercular development. However, with the acute phenomena the development of tubercles may be centralized in some conspicuous organ, as in the meninges of the brain, or of the brain and spinal cord, or in the lungs.
Etiology:—It is difficult to assign a cause to the acute manifestation of this disorder. The germs of the disease, from some ulcerating foci, may be thrown directly into the blood stream, where they develop rapidly and from whence the general deposit takes place. The condition occurs more frequently in youth and early adult life, and usually there has been a local tuberculosis, most often of the lymphatic glands, existing for some time.
The concurrence of acute infectious diseases with local tuberculosis is apt to precipitate an acute form of the disease. In some cases the tuberculous material is discharged by ulceration into the thoracic duct, passing thus directly into the blood current.
Symptomatology:—When there is general infection, which is usually designated as the typhoid form of the disease, it is observed that there is a sudden decline in the patient's health. He complains of general indisposition for a number of days, there is chilliness, extreme languor, headache, with some vertigo, and fever. It will be found that the temperature has been running perhaps for two or three days at from 100° to 103° F. One peculiarity of this fever is that it is very irregular in character: if there are remissions, they are as apt to occur in the evening as in the morning.
A feature somewhat similar to malaria is that when the temperature is high, sweating may occur, rather abruptly, with or followed by a sudden decline in the temperature, which may become sub-normal. The sweating is apt to be very profuse, and the pulse, feeble from the first, is always rapid; the pulse rate does not sustain its usual relationship to the temperature, but varies greatly.
Symptoms similar to those of typhoid fever appear quite early, the tongue becomes dry, there is a deficiency of all secretions, the mucous membranes are red, the tongue is thin, pointed and coated with a brown coat which becomes rapidly darker. The patient is dull, inclined to stupor and there may be more or less delirium. The bright red flush on the cheek, peculiar to hectic, is usually present. The respirations are rapid and a peculiar pallor overspreads the countenance, although in some cases cyanosis develops early. Prostration, emaciation and anemia follow in a short time.
So similar are the manifestations of this disease to those of typhoid fever that it is often with great difficulty that a differential diagnosis is made. The absence of the red spots, the absence of the Widal reaction are in part confirmatory, but it is only when the bacilli are found that the diagnosis is assured. Enlargement of the spleen, tympanites and acute and persistent diarrhea, with hemorrhage, may be present in either case. Herpes labialis is apt to be present in tuberculosis, and in persistent malarial fever, but is not present in typhoid with no malarial complications. Epistaxis, common in typhoid, is unusual in tuberculosis.
The septic cachexia, the rapid and prolonged prostration, the suddenly increasing or erratic temperature, the abrupt occurrence of extreme sweating are all unusual in typhoid.
When the pulmonary type of this disorder develops, as it does, more frequently in children than in adults, and often as a result of the infectious diseases of children, the symptoms are similar to those of acute bronchitis. The patient is feeble from the first, the debility is rapidly progressive, and with adults there is great anxiety. There may be chilliness and fever from the first observance of the debility, or these may be delayed for a few days, when with the chill the temperature rises abruptly. There is dyspnoea, cyanosis and severe irritating and persistent cough.
The respirations are very rapid, but the expectoration is not usually characteristic or severe, although it may be rusty colored, as in pneumonia, and there may be hemoptysis. The pulse is feeble, easily compressible and rapid, often irregular. In the later stages these symptoms are aggravated and the breathing becomes very difficult. Upon physical examination there are friction sounds and broncho-vesicular murmurs, with increased dulness. The signs are not dissimilar to those found in a severe case of bronchitis.
Diagnosis:—In the diagnosis of the pulmonic form the fact of tubercular conditions having previously existed is probably the strongest factor. The disproportion between the area of involvement and the cyanosis and dyspnoea is another factor. There is apt to be present other local manifestations of the infection which assist in the diagnosis. A compensatory emphysema may produce exaggerated resonance when dulness was anticipated.
