Post 09 - Not Miliary TB: High-Density, Variable-Sized Nodules in a Flour-Mill Worker

Not all small nodules are miliary. A history often helps getting to the diagnosis.

Bhavin Jankharia

11 May 2026

60-years old non-smoker man working in a traditional flour mill for 30 years presented with breathlessness.

His CT scan showed multiple small, diffuse nodules (Fig. 1) (red arrows) and moderate centrilobular emphysema (green arrow).

He was diagnosed to have miliary tuberculosis and put on treatment and didn't improve.

A closer look at the nodules shows they are high density (arrows in Fig. 2) and they are variable-sized (Fig. 3).

Miliary nodules by definition are 2-3 mm sized randomly distributed nodules - and are same-sized (Fig. 4 - another patient).

If you look at the flow-chart of diffuse small nodules (Fig. 5), random variable-sized nodules are NOT miliary. The diagnosis includes metastases, vasculitis, non-TB infection and silicosis.

Our patient worked in a flour-mill for 30 years. Fig. 6 shows why and how they get silicosis.

History matters. In a patient who has worked in a flour-mill, diffuse small nodules should mean silicosis, not miliary TB, just from the history. Plus in this case, the nodules are NOT "miliary", but variable-sized, high-density nodules, typical of silicosis.