{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T02:46:29Z","timestamp":1760150789058,"version":"build-2065373602"},"reference-count":50,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2023,12,31]],"date-time":"2023-12-31T00:00:00Z","timestamp":1703980800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JoF"],"abstract":"<jats:p>Background: A miliary pattern on chest imaging is often attributed to tuberculosis (TB) infection. However, a myriad of conditions can cause a miliary pattern, many of which are imminently life-threatening. Research Question: The primary aim of our study is to elucidate the potential causes of miliary chest imaging patterns to improve workup and empiric therapy selection. The secondary aims are to discern the predictors of miliary disease etiology and to determine whether appropriate empiric antimicrobial therapies were given. Study Design and Methods: In this retrospective cohort study, we searched a radiology database for patients with chest imaging studies described by the word \u201cmiliary\u201d. Subjects were excluded if they were under 18 years of age and if there were insufficient objective data to support a miliary disease etiology. A radiologist independently reviewed all imaging studies, and studies that did not appear to have a true miliary pattern were excluded. The collected data include patient demographics, immunocompromising risk factors, conditions associated with miliary disease, \u03b2-D-glucan levels, serum eosinophil count, and empiric therapies received. Results: From our 41-patient cohort, 22 patients (53.7%) were clinically diagnosed with coccidioidomycosis, 8 (19.5%) with TB, 7 (17.1%) with metastatic solid cancer, 1 (2.4%) with lymphoma, 1 (2.4%) with other (Mycobacterium simiae), and 3 (7.3%) with unknown diseases (the sum equals 42 patients because one individual was diagnosed with both coccidioidomycosis and TB). All six patients with greater than 500 eosinophils\/\u03bcL were diagnosed with coccidioidomycosis. Of the 22 patients diagnosed with coccidioidomycosis, 20 (90.91%) were empirically treated with an antifungal regimen. Of the eight patients with TB, six were empirically treated for TB. Interpretation: Based on our data from a Coccidioides-endemic region with close proximity to tuberculosis-endemic areas, the leading cause of miliary disease is coccidioidomycosis, although TB and cancer are also common etiologies. Serum eosinophilia and elevated \u03b2-D-glucan levels were strongly predictive of coccidioidomycosis in our patient cohort with a miliary chest imaging pattern.<\/jats:p>","DOI":"10.3390\/jof10010029","type":"journal-article","created":{"date-parts":[[2023,12,31]],"date-time":"2023-12-31T06:00:21Z","timestamp":1704002421000},"page":"29","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Examining Miliary Disease Etiology in a Coccidioides-Endemic Center: A Retrospective Cohort Study"],"prefix":"10.3390","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5542-8563","authenticated-orcid":false,"given":"Ashley M.","family":"Scott","sequence":"first","affiliation":[{"name":"Department of Pulmonary and Critical Care Medicine, University of Arizona, Tucson, AZ 85721, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2582-4578","authenticated-orcid":false,"given":"James Ray","family":"Lim","sequence":"additional","affiliation":[{"name":"Department of Infectious Disease, University of Arizona, Tucson, AZ 85721, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Reubender","family":"Randhawa","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, University of Arizona, Tucson, AZ 85721, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jason","family":"Lee","sequence":"additional","affiliation":[{"name":"Department of Radiology, University of Arizona, Tucson, AZ 85721, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kavitha","family":"Yaddanapudi","sequence":"additional","affiliation":[{"name":"Department of Radiology, University of Arizona, Tucson, AZ 85721, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Brooke","family":"Rabe","sequence":"additional","affiliation":[{"name":"Department of Biostatistics, Bio5 Institute, University of Arizona, Tucson, AZ 85721, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Joshua","family":"Malo","sequence":"additional","affiliation":[{"name":"Department of Pulmonary and Critical Care Medicine, University of Arizona, Tucson, AZ 85721, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2023,12,31]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"bcr06.2008.0322","DOI":"10.1136\/bcr.06.2008.0322","article-title":"Miliary lung metastasis due to papillary thyroid carcinoma","volume":"2009","author":"Gkountouvas","year":"2009","journal-title":"BMJ Case Rep."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1613","DOI":"10.1111\/1759-7714.13946","article-title":"Diagnosis of miliary nodules as lung adenocarcinoma by cryobiopsy: A case report","volume":"12","author":"Morishita","year":"2021","journal-title":"Thorac. Cancer"},{"key":"ref_3","first-page":"209","article-title":"Roentgenologic-pathologic correlations of miliary pulmonary metastases","volume":"9","author":"Awai","year":"1991","journal-title":"Radiat. Med."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"48","DOI":"10.1177\/0049475515582326","article-title":"All that seems to be miliary mottling is not always due to tuberculosis: A case report","volume":"46","author":"Sneha","year":"2016","journal-title":"Trop. Doct."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"e00475","DOI":"10.1002\/rcr2.475","article-title":"Erdheim-Chester disease progression from miliary pulmonary nodules to large tumours","volume":"7","author":"Shiihara","year":"2019","journal-title":"Respirol. Case Rep."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"e523","DOI":"10.1016\/j.chest.2021.07.2161","article-title":"Case of a 57-Year-Old Man with Malignant Mesothelioma Presenting with Miliary Nodules on Chest Imaging","volume":"160","author":"Baltaji","year":"2021","journal-title":"Chest"},{"key":"ref_7","first-page":"101239","article-title":"Malignant lymphoma mimics miliary tuberculosis by diffuse micronodular radiographic findings","volume":"31","author":"Yagyu","year":"2020","journal-title":"Respir. Med. Case Rep."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"e27","DOI":"10.1200\/JCO.2013.50.6501","article-title":"Extranodal Marginal Zone Lymphoma Presenting as Miliary Lung Disease","volume":"34","author":"Abramson","year":"2016","journal-title":"J. Clin. Oncol."},{"key":"ref_9","first-page":"457","article-title":"Unusual presentation of hepatocellular carcinoma: A case report","volume":"66","author":"Gorusu","year":"2002","journal-title":"Conn. Med."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"5026","DOI":"10.1200\/JCO.2007.13.3215","article-title":"Metastatic Gastric Carcinoma in a 19-Year-Old Man","volume":"25","author":"Ku","year":"2007","journal-title":"J. Clin. Oncol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"833","DOI":"10.2169\/internalmedicine.1889-18","article-title":"Multiple Pulmonary Metastases of Cutaneous Squamous Cell Carcinoma","volume":"58","author":"Kushima","year":"2019","journal-title":"Intern. Med."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"293","DOI":"10.2214\/ajr.137.2.293","article-title":"Metastatic melanoma in the thorax: Report of 130 patients","volume":"137","author":"Chen","year":"1981","journal-title":"AJR Am. J. Roentgenol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"250","DOI":"10.1002\/dc.23416","article-title":"Metastatic alveolar soft part sarcoma of the lung: Metastatic alveolar soft part sarcoma of the lung\u2014A morphologic pitfall on cytology and aberrant CD10 expression on histology","volume":"44","author":"Nambirajan","year":"2016","journal-title":"Diagn. Cytopathol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"195","DOI":"10.1001\/archpedi.1995.02170140077012","article-title":"Radiological case of the month. Miliary pulmonary neuroblastoma","volume":"149","author":"Kalra","year":"1995","journal-title":"Arch. Pediatr. Adolesc. Med."},{"key":"ref_15","first-page":"357","article-title":"Malignant peripheral nerve sheath tumor with extensive miliary metastases: A case report","volume":"142","author":"Schaus","year":"1997","journal-title":"Gen. Diagn. Pathol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1127","DOI":"10.2169\/internalmedicine.1220-18","article-title":"Miliary Lung Metastases from Genital Large Cell Neuroendocrine Carcinomas","volume":"58","author":"Sekine","year":"2019","journal-title":"Intern. Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1186\/s40842-018-0064-5","article-title":"Rare Clinical Entity: Metastatic malignant struma ovarii diagnosed during pregnancy\u2014Lessons for management","volume":"4","author":"Lager","year":"2018","journal-title":"Clin. Diabetes Endocrinol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"e113","DOI":"10.1016\/j.athoracsur.2014.07.057","article-title":"Benign Metastasizing Leiomyomatosis of the Lungs Presenting a Miliary Pattern","volume":"98","author":"Orejola","year":"2014","journal-title":"Ann. Thorac. Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"e15","DOI":"10.1164\/rccm.201203-0427IM","article-title":"Miliary Pulmonary Lymphangioleiomyomatosis","volume":"187","author":"Xu","year":"2013","journal-title":"Am. J. Respir. Crit. Care Med."},{"key":"ref_20","first-page":"OJ05","article-title":"Meningotheliomatosis: A Rare Cause of Diffuse Miliary Pattern Pulmonary Opacities","volume":"10","author":"Gleason","year":"2016","journal-title":"J. Clin. Diagn. Res."},{"key":"ref_21","first-page":"5098","article-title":"Does miliary sarcoidosis really exist? A case report and review of the literature","volume":"26","author":"Lovrenski","year":"2022","journal-title":"Eur. Rev. Med. Pharmacol. Sci."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"e230776","DOI":"10.1136\/bcr-2019-230776","article-title":"Pulmonary alveolar microlithiasis: Often misdiagnosed in children","volume":"12","author":"Kumar","year":"2019","journal-title":"BMJ Case Rep."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"301","DOI":"10.1378\/chest.123.1.301","article-title":"Granulomatous Pneumonitis Following Exposure to the World Trade Center Collapse","volume":"123","author":"Safirstein","year":"2003","journal-title":"Chest"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"bcr1020115060","DOI":"10.1136\/bcr.10.2011.5060","article-title":"An unusual cause of miliary radiographic pattern","volume":"2011","author":"Fahim","year":"2011","journal-title":"BMJ Case Rep."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"482","DOI":"10.1539\/joh.16-0096-CS","article-title":"Investigation of rare chronic lipoid pneumonia associated with occupational exposure to paraffin aerosol","volume":"58","author":"Han","year":"2016","journal-title":"J. Occup. Health"},{"key":"ref_26","first-page":"e13385","article-title":"Vape-Associated Pulmonary Injury (VAPI) Presenting with a \u201cMiliary\u201d Pattern on Imaging","volume":"13","author":"Threadcraft","year":"2021","journal-title":"Cureus"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"461","DOI":"10.46497\/ArchRheumatol.2021.8282","article-title":"Sarcoid-like granulomatous reaction in the lung mimicking miliary tuberculosis in a patient receiving adalimumab for psoriasis","volume":"36","author":"Bayler","year":"2021","journal-title":"Arch. Rheumatol."},{"key":"ref_28","first-page":"2094625","article-title":"Cryptogenic Organizing Pneumonia with a Rare Radiographic Presentation of a Diffuse Micronodular Pattern Mimicking Miliary Lung Infiltration: A Case Report and Review of the Literature","volume":"2020","author":"Kewcharoen","year":"2020","journal-title":"Case Rep. Pulmonol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"225","DOI":"10.1164\/rccm.201306-1078IM","article-title":"Multifocal Micronodular Pneumocyte Hyperplasia Mimicking Miliary Tuberculosis","volume":"189","author":"Lee","year":"2014","journal-title":"Am. J. Respir. Crit. Care Med."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"51","DOI":"10.4329\/wjr.v3.i2.51","article-title":"Miliary nodules due to secondary pulmonary hemosiderosis in rheumatic heart disease","volume":"3","author":"Agrawal","year":"2011","journal-title":"World J. Radiol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"79","DOI":"10.1186\/1752-1947-1-79","article-title":"Fatal miliary Coccidioidomycosis in a patient receiving infliximab therapy: A case report","volume":"1","author":"Rogan","year":"2007","journal-title":"J. Med. Case Rep."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"312","DOI":"10.1097\/00005792-198609000-00004","article-title":"Fungemia due to Coccidioides immitis. An analysis of 16 episodes in 15 patients and a review of the literature","volume":"65","author":"Ampel","year":"1986","journal-title":"Medicine"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"112","DOI":"10.1155\/2009\/763018","article-title":"Computed tomographic scan evaluation of pulmonary blastomycosis","volume":"20","author":"Ronald","year":"2009","journal-title":"Can. J. Infect. Dis. Med. Microbiol."},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Yu, X., Miao, K., Zhou, C., Cai, Y., Huang, X., Chen, Y., Chen, M., Cai, H., and Zhang, L.T. (2018). Marneffei infection complications in an HIV-negative patient with pre-existing pulmonary sarcoidosis: A rare case report. BMC Infect. Dis., 18.","DOI":"10.1186\/s12879-018-3290-7"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"464","DOI":"10.5603\/ARM.a2021.0051","article-title":"Acute Pulmonary Histoplasmosis Masquerading as Miliary Tuberculosis in A Non-Endemic Region","volume":"89","author":"Agarwal","year":"2021","journal-title":"Adv. Respir. Med."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"e151","DOI":"10.1259\/bjr\/20940804","article-title":"Case report: A rare cause of miliary nodules\u2014Allergic bronchopulmonary aspergillosis","volume":"82","author":"Agarwal","year":"2009","journal-title":"Br. J. Radiol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"189","DOI":"10.1016\/S1473-3099(05)70027-X","article-title":"Disseminated cryptococcosis resembling milliary tuberculosis in an HIV-1-infected patient","volume":"5","author":"Pomar","year":"2005","journal-title":"Lancet Infect. Dis."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"462","DOI":"10.4103\/0971-4065.106048","article-title":"Disseminated candidiasis 18 years after renal transplantation","volume":"22","author":"Bismay","year":"2012","journal-title":"Indian J. Nephrol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"693","DOI":"10.1378\/chest.96.3.693","article-title":"Miliary PCP in AIDS","volume":"96","author":"Wasser","year":"1989","journal-title":"Chest"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1203","DOI":"10.1378\/chest.11-0425","article-title":"Lung Manifestations in an Autopsy-Based Series of Pulmonary or Disseminated Nontuberculous Mycobacterial Disease","volume":"141","author":"Birkenkamp","year":"2012","journal-title":"Chest"},{"key":"ref_41","first-page":"65","article-title":"Actinomycosis of the breast and lungs","volume":"32","author":"Fred","year":"2019","journal-title":"Proceedings (Bayl. Univ. Med. Cent.)"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1111\/j.1365-2559.1993.tb00073.x","article-title":"Legionnaire\u2019s disease mimicking pulmonary miliary tuberculosis in the immunocompromised","volume":"22","author":"Cluroe","year":"1993","journal-title":"Histopathology"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"151","DOI":"10.1007\/s12024-018-0026-3","article-title":"Melioidosis mimicking miliary tuberculosis","volume":"15","author":"Tan","year":"2019","journal-title":"Forensic. Sci. Med. Pathol."},{"key":"ref_44","first-page":"107","article-title":"Cytomegalovirus pneumonia in bone marrow transplant recipients: Miliary and diffuse patterns","volume":"122","author":"Beschorner","year":"1980","journal-title":"Am. Rev. Respir. Dis."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"519","DOI":"10.1097\/MS9.0000000000000231","article-title":"Delayed acyclovir therapy for disseminated varicella zoster in an adult kidney transplant recipient: A case report and literature review","volume":"85","author":"Alsultan","year":"2023","journal-title":"Ann. Med. Surg."},{"key":"ref_46","first-page":"12","article-title":"Pulmonary Strongyloides stercoralis infection","volume":"11","author":"Dogan","year":"2014","journal-title":"Respir. Med. Case Rep."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"767","DOI":"10.1016\/j.amjmed.2018.12.030","article-title":"Clinical Characteristics and Etiologies of Miliary Nodules in the US: A Single-Center Study","volume":"132","author":"Salahuddin","year":"2019","journal-title":"Am. J. Med."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"451","DOI":"10.3109\/02841859909177764","article-title":"HRCT in Miliary Lung Disease","volume":"40","author":"Voloudaki","year":"1999","journal-title":"Acta Radiol."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"118","DOI":"10.3389\/fpubh.2017.00118","article-title":"Tuberculosis Treatment Completion in a United States\/Mexico Binational Context","volume":"5","author":"Valencia","year":"2017","journal-title":"Front. Public Health"},{"key":"ref_50","unstructured":"Centers for Disease Control and Prevention (2023, March 08). Tuberculosis: Data and Statistics, Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Available online: www.cdc.gov\/tb\/statistics\/default.htm#:~:text=TB%20case%20counts%20and%20incidence,the%20United%20States%20since%201992.&text=In%202022%2C%208%2C300%20TB%20cases,2.5%20cases%20per%20100%2C000%."}],"container-title":["Journal of Fungi"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2309-608X\/10\/1\/29\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T21:45:09Z","timestamp":1760132709000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2309-608X\/10\/1\/29"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,12,31]]},"references-count":50,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2024,1]]}},"alternative-id":["jof10010029"],"URL":"https:\/\/doi.org\/10.3390\/jof10010029","relation":{},"ISSN":["2309-608X"],"issn-type":[{"type":"electronic","value":"2309-608X"}],"subject":[],"published":{"date-parts":[[2023,12,31]]}}}