Miliary TB Without Microbiological Confirmation in a Post-Menopausal Female: A Case From a High-Burden Region

Miliary tuberculosis (TB) presents significant diagnostic challenges in resource-limited, high-burden regions when microbiological confirmation is unattainable. We describe a 65-year-old post-menopausal Nepalese woman with prolonged fever, anemia, and constitutional symptoms. Initial chest radiography was inconclusive, but contrast-enhanced computed tomography (CECT) revealed diffuse miliary nodules, calcified lymphadenopathy, and pleural effusion. Microbiological confirmation was precluded by the inability to expectorate and refusal of bronchoscopy. Empirical anti-TB therapy (isoniazid, rifampicin, pyrazinamide, and ethambutol) was initiated based on radiological findings and epidemiological context (Nepal TB prevalence: 245/100,000). The patient showed symptomatic and hematological improvement at follow-up despite declining invasive diagnostics. This case underscores CT imaging's critical role in diagnosing miliary TB when microbiological evidence is unavailable and supports ethical empirical treatment in elderly patients from endemic regions where diagnostic limitations exist.