A 71-year-old man was admitted to the hospital complaining of productive cough and weight loss. Physical examination showed fine bilateral basal crackles. Laboratory findings showed elevated liver enzymes. Tuberculin skin test and sputum smear for acid-fast bacilli were negative. On the fifth day of admission, he deteriorated and developed severe respiratory distress. A chest radiograph demonstrated worsening pulmonary infiltrates. He was electively intubated and was put on a mechanical ventilator. The chest CT scan revealed diffuse bilateral pulmonary nodules and airspace disease. Based upon the clinical suspicion of acute respiratory distress syndrome associated with miliary tuberculosis (TB), empiric treatment with antituberculosis and systemic steroids was started. He was extubated after 6 days. The diagnosis of miliary TB was confirmed by a thoracoscopic lung biopsy. He was discharged with a near normal chest radiograph and was followed up as an outpatient.
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