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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 11  |  Issue : 5  |  Page : 58-61

Tuberculosis presenting as immune thrombocytopenia


Department of General Medicine, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India

Date of Submission27-Nov-2021
Date of Decision29-Apr-2022
Date of Acceptance01-May-2022
Date of Web Publication30-Aug-2022

Correspondence Address:
M Nageshwar Rao
Professor and Head, Department of General Medicine, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad 500 082, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcsr.jcsr_71_21

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  Abstract 


A 19-year-old male presented with chief complaints of generalised weakness and unintentional weight loss from 50 Kg to 45 Kg within a span of 1 month. He complained of fever for 15 days and had developed petechiae over bilateral upper limbs and bilateral subconjunctival haemorrhage. Laboratory investigations done elsewhere showed platelet count of 10,000/mm3. On further investigation, Widal test, dengue serology, and smear examination for malarial parasite, antinuclear antibodies, and viral markers were negative. Abdominal ultrasonography showed multiple conglomerative enlarged lymph nodes in peripancreatic, peripatetic and paracaval, with few of them showing necrosis and loss of hilum and minimal ascites. Bone marrow examination showed megakaryocytic hyperplasia features, suggestive of immune thrombocytopenic purpura (ITP). No improvement in the platelet count was noted with intravenous methylprednisolone. On examination, the patient had ecchymotic patches over bilateral upper limbs and bilateral subconjunctival haemorrhages. Bilateral supraclavicular lymph nodes were palpable, non-tender, mobile, measuring 3 cm × 3 cm in the right side and 2 cm × 2 cm in the left side and firm in consistency. Cervical lymph node biopsy showed caseous necrotising granulomatous inflammation. Contrast-enhanced computed tomography neck, chest and abdomen showed multiple enlarged conglomerated heterogeneous enhancing lymph nodes with central non-enhancing areas s/o necrosis noted in the neck, mediastinum and abdomen. Tuberculin skin test (Mantoux test) revealed induration of 20 mm. The patient was started on eltrombopag, and four doses of intravenous immunoglobulin were given without improvement. The patient was started on liver-friendly anti-tuberculosis treatment in view of deranged liver function tests with isoniazid, rifampicin, ethambutol and levofloxacin and later pyrazinamide was added. The platelet count increased after 1 month of ATT to 40,000, and after 2 months, the count was 100,000/mm3.

Keywords: Immune thrombocytopenia, lymph nodes, tuberculosis


How to cite this article:
Moka D, Pappu SS, Badavath R, Rao M N. Tuberculosis presenting as immune thrombocytopenia. J Clin Sci Res 2022;11, Suppl S1:58-61

How to cite this URL:
Moka D, Pappu SS, Badavath R, Rao M N. Tuberculosis presenting as immune thrombocytopenia. J Clin Sci Res [serial online] 2022 [cited 2022 Oct 6];11, Suppl S1:58-61. Available from: https://www.jcsr.co.in/text.asp?2022/11/5/58/355064




  Introduction Top


Tuberculosis (TB) has variable presentations ranging from classic presentation of respiratory symptoms to less common presentations such as involvement of lymph nodes, gastrointestinal system and rare haematological manifestations. Haematological manifestations of TB vary from common presentations such as anaemia and pancytopenia to rare presentations such as immune thrombocytopenia.[1] Thrombocytopenia can be either due to infiltration of bone marrow or immune-mediated thrombocytopenia.


  Case Report Top


A 19-year-old male student with no prior comorbidities presented with chief complaints of generalised weakness and loss of weight from 50 to 45 Kg within a span of 1 month unintentionally. He had complained of fever for 15 days which was low grade, occurring during evening time from 5 pm to 10 pm, not associated with chills and rigors. He had developed petechiae over bilateral upper limbs and also developed bilateral subconjunctival haemorrhage.

Laboratory testing elsewhere revealed haemoglobin 12.7 g/dL, total leucocyte count 7500/mm3 and platelets 10,000/mm3. Widal test was negative; dengue serology; smear for malarial parasite; antinuclear antibody and viral markers were negative. Abdominal ultrasonography showed multiple conglomerated enlarged lymph nodes in peripancreatic, peripatetic and paracaval, with few of them showing necrosis and loss of hilum and minimal ascites. Bone marrow examination showed megakaryocytic hyperplasia features suggestive of immune thrombocytopenic purpura (ITP). Administration of pulse methylprednisolone for 3 days did not result in improvement in platelet count.

On examination, the patient was conscious. Vitals were stable. Jugular venous pulse was not elevated. Oral cavity was normal. There were no pallor, no interest, no cyanosis, no clubbing, no pedal oedema and no koilonychia. He had also developed ecchymotic patches over bilateral upper limbs and bilateral subconjunctival haemorrhages. Bilateral supraclavicular lymph nodes were palpable, non-tender, mobile, measuring 3 cm × 3 cm in the right side and 2 cm × 2 cm in the left side and firm in consistency. There were no inguinal lymph nodes. Abdomen was soft, non-tender. There was no palpable hepatosplenomegaly; bowel sounds normal. On neurological examination, Glasgow coma scale score was E4V5M6, pupils were reactive, facial symmetry was maintained, there were no focal neurological deficits.

Laboratory investigations in our hospital showed haemoglobin 11.4 g/dL, total leucocyte count 9600/mm3 and platelet count 10,000/mm3. Blood cultures showed no growth. Antinuclear antibody was negative, viral markers were negative and Brucella serology was negative. Bone marrow showed normal cellularity with increased megakaryocytes [Figure 1].
Figure 1: Photomicrograph of peripheral blood smear showing thrombocytopenia (Giemsa, ×40) (a); photomicrograph of bone marrow aspiration showing megakaryocyte hyperplasia (Giemsa, ×40) (b); bone marrow aspiration showing megakaryocyte hyperplasia (Giemsa, ×1000), bone marrow biopsy showing megakaryocyte hyperplasia in a low-power field (Giemsa, ×40) (d)

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Cervical lymph node biopsy showed caseous necrotising granulomatous inflammation [Figure 2]. Cervical lymph node biopsy Xpert MTB/RIF® testing was not done.
Figure 2: Photomicrograph of lymph node biopsy showing effaced architecture (Haematoxylin and eosin, ×4) (a); well-formed epithelioid granulomas with central necrosis (Haematoxylin and eosin, ×40) (b); well-formed epithelioid granulomas with central necrosis (Haematoxylin and eosin, ×100) (c); negative Ziehl–Neelsen stain for acid-fast bacilli (d)

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Contrast-enhanced computed tomography showed multiple enlarged conglomerated heterogeneous enhancing lymph nodes with central non-enhancing areas s/o necrosis noted in the neck, mediastinum and abdomen [Figure 3] and [Figure 4]. Tuberculin skin test (Mantoux test) showed 20 mm induration.
Figure 3: Computed tomography of the chest showing lymph nodes with central necrosis in pre- and paratracheal region

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Figure 4: Computed tomography of the abdomen showing peripancreatic and aortocaval lymph nodes with necrosis

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Initially, he was treated with methylprednisolone, but platelet count did not improve. The patient was started on eltrombopag, and four doses of intravenous immunoglobulin (IVIG) were given in view of ongoing bleeding but no improvement.

The patient was then started on liver-friendly anti-TB treatment (ATT) in view of deranged liver function tests and later pyrazinamide was added. The platelet count increased after 1 month of ATT to 40,000/mm3. At the end of 2 months, it was 100,000/mm3, and after 6 months of ATT, the counts were stable at 150,000/mm3


  Discussion Top


TB is an endemic disease in India. TB has been associated with several haematological manifestations including anaemia, pancytopenia, thrombocytopenia and leucocytosis. Coombs' positive haemolytic anaemia and ITP are exceedingly rare and life-threatening complications of TB.[2] Primary ITP is an autoimmune disorder characterised by isolated thrombocytopenia (peripheral blood platelet count <100 × 109/L) in the absence of other causes or disorders that may be associated with thrombocytopenia. All forms of immune-mediated thrombocytopenia except primary ITP come under secondary ITP.[3]

Thrombocytopenia in TB can occur because of a defect in platelet production related to bone marrow infiltration, side effects of ATT, splenomegaly, histiocytosis, thrombotic thrombocytopenic purpura (TTP), disseminated intravascular coagulation (DIC) or immune-mediated platelet destruction.[4] It has been postulated that the activation of B-lymphocytes by Mycobacterium leads to the production of antiplatelet antibodies.[5]

In our patient, immunosuppression alone did not result in improvement in platelet count; concomitant ATT was needed as an adjunct.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest



 
  References Top

1.
Weber SF, Bélard S, Rai S, Reddy R, Belurkar S, Saravu K. Immune thrombocytopenia secondary to tuberculosis: A case and review of literature. Int J Tuberc Lung Dis 2017;21:466-70.  Back to cited text no. 1
    
2.
Uzun O, Turgut M, Erkan L. Two unusual hematologic presentations of tuberculosis. Ann Saudi Med 2005;25:496-500.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Rodeghiero F, Stasi R, Gernsheimer T, Michel M, Provan D, Arnold DM, et al. Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: Report from an international working group. Blood 2009;113:2386-93.  Back to cited text no. 3
    
4.
Al Argan RJ, Al Elq AH. Tuberculosis-associated immune thrombocytopenia: A Case Report. Saudi J Med Med Sci 2018;6:160-4.  Back to cited text no. 4
    
5.
Cines DB, Blanchette VS. Immune thrombocytopenic purpura. N Engl J Med 2002;346:995-1008.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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