CTICasesCytomegalovirus Infection with a Miliary Pattern in a Kidney Transplant Recipient
Imaging findings
CT in a kidney transplant recipient with fever and cough shows a miliary pattern of tiny, truly randomly distributed nodules, better appreciated on a thinner MIP. The nodules are uniform in size and are not clumped; some touch the fissures and interlobular septa, but they do not cluster preferentially along them and do not coalesce in the manner of sarcoid nodules.
Key takeaways
A miliary pattern carries a fairly narrow differential, and in a transplant recipient it is usually infectious: histoplasmosis is common in endemic areas, blastomycosis occurs though those patients tend to be sicker with established disseminated disease, and coccidioidomycosis and mycobacterial disease including tuberculosis and non-tuberculous mycobacteria are also considerations. Viral causes are less common but real, and bronchoalveolar lavage here returned cytomegalovirus, which was disseminated elsewhere in the body. Imaging cannot distinguish fungal, viral, and mycobacterial causes of a miliary pattern. A random distribution implies haematogenous spread, which is what separates miliary disease from the centrilobular nodularity of bronchiolitis.
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