A 75 -year-old recipient of a cadaveric kidney transplant on chronic immunosuppressive therapy with prednisone and cyclosporine presented with 2 months of fever as his only symptom; other than fever, his initial physical examination was unremarkable. Complete blood count, electrolytes, blood and urine cultures were normal, as were routine, fungal and mycobacterial studies of the sputum, computed tomography of the chest, abdomen and pelvis and transoesophageal echocardiogram. Three weeks later he developed lower gastrointestinal bleeding and a colonoscopicbiopsy showed granulomas, with positive stains for acid-fast bacilli. Within days of the biopsy acid-fast bacilli were found in the urine and repeat tomography of his thorax showed a bilateral miliary pattern. Colon cultures grew Mycobacterium tuberculosis and his fevers promptly resolved following the initiation of antituberculous treatment.This case illustrates the sometimes obscure presentation of miliary tuberculosis. The term miliary (resembling amillet seed) refers to the very small, discrete granulomatous lesions in lungs and other organs that result from mycobacterial bacteraemia and subsequent dissemination to a variety of tissues. Fever of unknown origin has been described as one mode of presentation of miliary tuberculosis.
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