We report the case of a 23-year-old Japanese female patient with Sjögren's syndrome who had been treated with methotrexate and azathioprine for 10 years. She experienced fatigue, fever, and lower back pain, which had persisted for 2 months, and presented with hilar and mediastinal lymphadenopathy on contrast-enhanced chest computed tomography (CT). Further examination revealed no active lesions in the lung fields; however, multiple lesions were detected in the lymph nodes, bone, subcutaneous tissue, peritoneum, and colon. Sputum specimens could not prove the presence of Mycobacterium tuberculosis, and a T-SPOT®.TB test was negative. We performed endobronchial ultrasound-guided transbronchial needle aspiration and obtained a specimen from the mediastinal lymph nodes. Although an acid-fast bacilli smear and polymerase chain reaction for M. tuberculosis were negative, the specimen showed granulomatous lesions and M. tuberculosis was subsequently cultured. We finally diagnosed disseminated tuberculosis.
Clinicians should be alert to the possibility of disseminated tuberculosis even in the absence of miliary nodules in the lung and negative interferon gamma release assay (IGRA) results.