Miliary Tuberculosis: A Comprehensive Scholarly Review of Pathophysiology, Clinical Diagnosis, and Interprofessional Management Strategies in the Modern Era

Miliary tuberculosis represents a potentially fatal disseminated form of tuberculosis resulting from lymphohematogenous spread of Mycobacterium tuberculosis to multiple organ systems. This condition, characterized by the formation of millet-seed-sized granulomatous lesions (1–2 mm) distributed throughout the lungs and extrapulmonary tissues, carries substantial morbidity and mortality, particularly when diagnosis is delayed. This comprehensive review examines the current understanding of miliary tuberculosis, encompassing its historical recognition by John Jacobus Manget in 1700 to contemporary diagnostic approaches. The epidemiology demonstrates a bimodal age distribution with peaks in young adults and older individuals, while the pathophysiology involves failure of cell-mediated immunity enabling hematogenous dissemination from a primary pulmonary or reactivation focus. Clinically, patients may present with either acute miliary tuberculosis—typically in younger patients with constitutional symptoms and organ-specific manifestations—or cryptic miliary tuberculosis—predominantly affecting elderly patients with fever of unknown origin and normal chest radiographs. Diagnostic evaluation requires a high index of suspicion and integrated approach combining imaging studies (chest radiography demonstrating classic miliary mottling or high-resolution computed tomography for early detection), laboratory investigations (including molecular methods such as Gene Xpert MTB/RIF and line probe assays), and histopathological confirmation (demonstrating caseating granulomas with or without Langhans giant cells). The World Health Organization-recommended 6-month antitubercular regimen (isoniazid, rifampicin, pyrazinamide, ethambutol) constitutes standard therapy, though prolonged treatment (9–12 months) is indicated for skeletal, central nervous system, or multidrug-resistant involvement. Corticosteroids have demonstrated benefit in specific scenarios including tuberculous meningitis, adrenal insufficiency, and immune reconstitution inflammatory syndrome. Complications are numerous and include acute respiratory distress syndrome, multiorgan dysfunction, tuberculous meningitis, and disseminated intravascular coagulation. Prognosis depends critically upon timeliness of diagnosis, with mortality rates of 15–20% in children and 25–30% in adults. An interprofessional healthcare team approach—incorporating physicians, nurses, pharmacists, and community health workers—is essential for optimizing patient outcomes through early recognition, appropriate treatment initiation, and ensuring treatment adherence.