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Miliary Tuberculosis with Severe Pneumonia without Abnormal Chest Sounds in a Covid-19 Pandemic

Background: Tuberculosis (TB) is still causing deaths in children in TB endemic countries. Majority (80%) occur in the lungs, with 5% being miliary TB. It is an Interstitial Lung Disease (ILD) with similar clinical, physiological and radiological features to other ILD and affects mainly infants and children with a high mortality rate despite available treatment. Case Presentation: A three-month old male presented during the COVID-19 pandemic with fever of 2 weeks, cough of one week, fast and difficult breathing of 6 days’ duration. He received BCG vaccine 16 days after birth despite being unknowingly exposed to the TB contact from birth. He was acutely ill looking, with severe pneumonia and SPO2 of 76% in room air. Respiratory examination showed broncho vesicular breath sounds with no added sounds. A diagnosis of Severe pneumonia? Pneumocystis Jiroveci Pneumonia (PJP) and R/O COVID-19 was made. Subsequent reviews excluded PJP and COVID-19 and the final diagnosis was Disseminated (Miliary) TB. He was successfully treated with anti-TB medications for 12 months. Conclusion: Miliary TB presents with common and uncommon manifestations that may be confusing, and so a high index of suspicion with a careful history, focused systemic examination, imaging and bacteriological studies are strongly recommended for its early diagnosis.