For years I used to teach about the entity of ‘disseminated sclerosis’ in neurology. In my opinion, it was a very good terminology for that disease. But as medical fashions changed, the terminology was changed to ‘multiple sclerosis’ and today everybody talks of this, and the new generation may not even be aware that once upon a time the terminology for this was ‘disseminated sclerosis’. However call it good luck or bad luck, the word has come back and is being used even for fungal diseases like histoplasmosis.

Since many years I have been teaching that if a patient is HIV positive and/or if he has AIDS, then in this case TB may present as disseminated TB. Also, patients who are immuno-suppressed due to other causes, which may include alcohol, heavy tobacco/gutka consumption (in any form), certain patients of lymphoma and leukaemia, diabetes, patients on maintenance dose of steroids, patients having SLE etc, are more prone, and may get not only TB, but disseminated TB. The initial concept was that even polyserositis involving pericardium, pleura and peritoneum was an example of disseminated TB. Then we started seeing patients having glandular TB in the neck, also having pulmonary TB, although initially we were taught that glandular TB is caused by different type of tubercle bacilli called mycobacteria Bovis.

Lately for last few years I have been teaching that glandular TB in the neck behaves differently and its response to AKT is unpredictable, with some of the patients landing up with cold abscesses or new lymphnodes appearing elsewhere during the treatment. In the past steroids were considered for glandular TB, but after seeing such patients also having lung TB, I am hesitating to prescribe steroids.

However, I am writing this article to bring out the point that disseminated TB is appearing in a big way in modern days. One should not mix up this disease with miliary TB, which spreads through the blood and is of course disseminated all over the body. I am seeing more and more patients having TB of the lung along with

• The pleura
• The hilar glands involvement
• Involvement of the glands in the abdomen e.g. portahepatic, or at superior or inferior mesenteric origin of the vessels from aorta
• Involvement of the vertebra
• Involvement of the ribs
• Presence of cold abscess in chest or abdomen or even without any bony involvement.

The lesson to be learnt is that even in patients having negative HIV or having no other immuno-suppression, if one wants to exclude TB, even a so-called normal Chest X-ray will not be acceptable. Once the patient has presented with complaints of asthenia, weakness, loss of weight, loss of appetite, anaemia, then even without any evidence of fever one should look out for disseminated TB especially if the ESR is more than 50 mm at the end of the one hour. A shortcut to the diagnosis would be to ask for CT scan of the chest and full abdomen and pelvis, an investigation, which of course is quite expensive.

At present I am treating an eleven year old boy, who looks little weak but is otherwise normal and has a cold abscess in front of the sternum, tuberculosis involving two ribs on the right side, enlarged right mediastinal hilar glands and tuberculosis of pericardium with mild effusion! Of course, since he came from a well-to-do family and could afford a CT scan which gave the diagnosis!