Prolonged Cholestasis as an Initial Presentation of Miliary Tuberculosis in a Pediatric Patient

Abstract

Miliary tuberculosis is a severe form of tuberculosis resulting from hematogenous dissemination of Mycobacterium tuberculosis and may cause respiratory failure and multiorgan involvement in infants. Hepatic involvement is uncommon and may present as prolonged cholestasis and granulomatous hepatitis, making the diagnosis particularly challenging. We report an infant with miliary tuberculosis presenting with infantile cholestasis and acute respiratory failure. A 2-month-old infant presented with persistent cholestasis developed at 6 weeks of age and acute respiratory failure requiring noninvasive mechanical ventilation. Initial evaluation, including intraoperative cholangiography, excluded biliary atresia, and an extensive infectious, metabolic, autoimmune, immunologic, and genetic evaluation did not identify an alternative cause. Chest computed tomography demonstrated bilateral ground-glass opacities and peripheral micronodules in a miliary pattern. Liver biopsy showed granulomatous hepatitis with focal central necrosis and multinucleated giant cells. The diagnosis of Mycobacterium tuberculosis was confirmed by sputum polymerase chain reaction and acid-fast bacilli culture. A four-drug anti-tuberculosis regimen led to complete clinical, radiological, and biochemical resolution, with full recovery by 4 months of age. Miliary tuberculosis should be considered in infants presenting with severe respiratory failure, prolonged neonatal cholestasis, and granulomatous hepatitis, particularly in endemic regions. Early recognition of miliary pulmonary patterns on imaging and prompt initiation of targeted anti-tuberculosis therapy is critical to improve outcomes and ensure a favorable prognosis.