More compatible with 'cryptic miliary tuberculosis' To the Editor-I read with interest the case report published by Shea and Ip titled "Pulmonary tuberculosis complicating asbestosis". 1 On reading the details, I could not agree on the authors' interpretation of the findings and the diagnosis of asbestosis. While it is beyond doubt that the findings of calcified pleural plaques point towards the diagnosis of a form of "asbestos-related pleural disease", this condition has to be distinguished from 'asbestosis' although the two conditions may coexist in some patients. Asbestosis refers to scarring of the lung parenchyma as a result of heavy asbestos exposure. Radiological features are usually in the form of reticulation, linear and curvilinear opacities, and parenchymal bands. 2 These features were not obvious in the computed tomographic images shown. Rather, the prominent radiological findings were those of fine nodules which, in my view, were more compatible with a diagnosis of 'cryptic miliary tuberculosis'. Cryptic miliary tuberculosis is a form of tuberculosis which tends to occur in the elderly and presents with fever of unknown origin with negative bacteriological findings. 3 Diagnosis is difficult and often delayed. Given the clinical and radiological features of the case reported here, I think a more appropriate title would be "Cryptic miliary tuberculosis in an elderly patient with underlying asbestos-related pleural plaques".
A 67 year old woman presented with miliary tuberculosis. She was treated with streptomycin, isoniazid, rifampicin, ethambutol and pyrazinamide. However, she developed rifampicin-induced thrombocytopenia after 6 weeks of treatment, and skin rash, blood eosinophilia and pulmonary infiltrates after 8 weeks of therapy. The latter was found to be ethambutol related. Additional evidence, including blood and sputum eosinophilia and the rapidity of its response to corticosteroid, suggested that the pulmonary infiltrates might also be eosinophilic in nature. To the best of our knowledge, this constitutes the first report of such adverse drug reaction, induced by ethambutol.
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