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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 1  |  Page : 107-109

Immune thrombocytopenic purpura in a patient with disseminated tuberculosis: An unusual presentation


1 Department of Critical Care Medicine, Sri Balaji Action Medical Institute, New Delhi, India
2 Department of Internal Medicine, Sri Balaji Action Medical Institute, New Delhi, India

Date of Web Publication12-Mar-2019

Correspondence Address:
Prashant Nasa
Department of Critical Care Medicine, Sri Balaji Action Medical Institute, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_169_18

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  Abstract 


Pulmonary tuberculosis can have a wide variety of presentations including hematological manifestations. We report a case of a young male patient who presented with complaints of generalized petechiae, gum bleeding, systemic lymphadenopathy, and severe thrombocytopenia. His bone marrow revealed normal megakaryocytes, and in the absence of hepatosplenomegaly, a diagnosis of immune thrombocytopenic purpura (ITP) was made. The thrombocytopenia responded to course of intravenous immune globulin. The smear made from fine-needle aspiration of cervical lymph nodes showed acid-fast bacilli. This case highlights the rare association of extrapulmonary tuberculosis with ITP.

Keywords: Extrapulmonary tuberculosis with immune thrombocytopenic purpura, hematological manifestations of tuberculosis, immune thrombocytopenic purpura


How to cite this article:
Nasa P, Juneja D, Sehra S, Singh H K, Prasad DB. Immune thrombocytopenic purpura in a patient with disseminated tuberculosis: An unusual presentation. Int J Mycobacteriol 2019;8:107-9

How to cite this URL:
Nasa P, Juneja D, Sehra S, Singh H K, Prasad DB. Immune thrombocytopenic purpura in a patient with disseminated tuberculosis: An unusual presentation. Int J Mycobacteriol [serial online] 2019 [cited 2019 May 21];8:107-9. Available from: http://www.ijmyco.org/text.asp?2019/8/1/107/253956




  Introduction Top


Extrapulmonary tuberculosis can have a wide variety of manifestations including hematological. Thrombocytopenia in tuberculosis is uncommon and if present, it is a diagnostic dilemma to clinicians. It occurs most commonly through nonimmunologic means and manifesting typically in relation to pancytopenia that may develop secondary to granulomatous infiltration of the bone marrow.[1] However, immune thrombocytopenic purpura (ITP) in a patient with tuberculosis is exceedingly a rare event and is a diagnosis of exclusion.


  Case Report Top


A 21-year-old male was admitted with complaints of high-grade fever, loss of appetite for 35–40 days, petechial rashes, and bleeding gums for the last 2 days. He had received intravenous ceftriaxone 1 g 12 hourly for 3 days in a nursing home before coming to our hospital. There was no other family and personal history and of any other major systemic disease. On examination, the patient had petechiae and purpuric rash on the trunk, neck, and both upper limbs. Furthermore, on palpation, there were nontender, multiple, soft, rubbery, discrete, and mobile lymph nodes (largest 3 cm × 2 cm), involving bilateral deep cervical, axillary, and inguinal areas. On taking further history, the patient confirmed the presence of these swellings for more than a month. He was hemodynamic stable. On systemic examination, liver and spleen were not palpable, with no other systemic findings. The significant investigational findings were thrombocytopenia (platelet count – 1000/mm 3), multiple abdominal lymph nodes on ultrasound with no other organomegaly and multiple mediastinal lymphadenopathy with no lung parenchymal lesion on contrast-enhanced chest tomography chest. His other investigations are mentioned in [Table 1]. He was managed with single-donor apheresis platelets and other supportive management with a provisional diagnosis of hematological malignancy or ITP after performing bone marrow examination. On bone marrow aspirate, there were normal megakaryocytes with very few abnormal lymphocytes. He was started on intravenous immunoglobulin (IVIG) in view of persistent severe thrombocytopenia, 400 mg/kg/day for 3 days. The fine-needle aspiration of cervical lymph node showed multiple granulomas with central necrosis and acid-fast bacilli on smear [Figure 1]. He was started on the first-line antituberculosis treatment (isoniazid, rifampin, pyrazinamide, and ethambutol). His platelets showed improvement from day 4 (60 h after the first dose) and increased to 121,000/mm 3 on day 8 [Figure 2]. The patient was discharged on day 10 on antituberculosis drugs as the final diagnosis of extrapulmonary tuberculosis and ITP with advice of regular follow-up.
Table 1: Laboratory investigations

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Figure 1: Response of platelet count to intravenous immunoglobulin

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Figure 2: Fine needle aspiration of cytology of cervical lymph node Arrow showing granuloma

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  Discussion Top


Tuberculosis is a major public health problem worldwide with not only challenges in management but also in the diagnosis. Extrapulmonary tuberculosis can present with a wide variety of hematological manifestations such as anemia, leukopenia, pancytopenia, thrombocytopenia, myelofibrosis, and the hemophagocytic syndrome.[1],[2] Severe isolated thrombocytopenia in extrapulmonary tuberculosis is relatively uncommon. There are various pathophysiological hypotheses proposed for thrombocytopenia in tuberculosis which include defect in platelet production (marrow suppression), hemophagocytosis of all cell lineages in bone marrow, side effect of antituberculous therapy (especially rifampin), thrombotic thrombocytopenic purpura (TTP), or disseminated intravascular coagulopathy (DIC), and due to immune-mediated platelet destruction.[3],[4]

The ITP in extrapulmonary tuberculosis is very rare with very few cases reported in the literature.[3],[4],[5],[6],[7] It can be either due to the production of platelet antigen-specific antibodies or platelet surface membrane immunoglobulin G, which is generated by proliferating lymphocytes as a part of the immune response to infection.[3],[5] The characteristics of these patients are as follows:[3]

  1. More common in females
  2. Middle aged to the elderly, third to eighth decades of life
  3. Middle Eastern and Asian descent
  4. Most commonly associated with pulmonary tuberculosis (33%)
  5. Extrapulmonary tuberculosis and tubercular lymphadenitis are associated in only 19% of cases.


The principal diagnostic criteria for ITP are as follows:[7]

  1. Isolated thrombocytopenia with otherwise normal peripheral complete blood count and smear and normal marrow production
  2. Absence of hepatosplenomegaly
  3. Platelets response to classic ITP therapy (usually IVIG, IV anti-D, and possibly steroids).


Our case was challenging and unique in several aspects, as our patient was young (21 years) male, nonimmunocompromised, and presentation was with systemic lymphadenopathy involving multiple noncontiguous groups of lymph nodes and severe thrombocytopenia. There was no hepatosplenomegaly and absence of pulmonary involvement. The bone marrow showed normal megakaryocytes and the absence of granuloma or hemophagocytosis. Absence of renal dysfunction, neurological abnormalities, and evidence of hemolysis on peripheral smear rules out TTP. DIC was ruled out with normal prothrombin time. There was also no history of any offending drug causing thrombocytopenia. The thrombocytopenia was very severe with platelet count <10,000/mm 3 and showed a good response to IVIG. The presence of thrombocytopenia with tubercular lymphadenitis in adults is very rarely reported.[8],[9],[10]


  Conclusions Top


ITP is a rare but potentially treatable presenting manifestation of extrapulmonary tuberculosis infection. It should be considered in differential diagnosis of patients with tuberculosis presenting with isolated thrombocytopenia. The early diagnosis with the use of specific therapies such as IVIG and antituberculosis therapy should be considered in these cases.

Declaration of patient consent

We certify that we have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Singh KJ, Ahluwalia G, Sharma SK, Saxena R, Chaudhary VP, Anant M, et al. Significance of haematological manifestations in patients with tuberculosis. J Assoc Physicians India 2001;49:788, 790-4.  Back to cited text no. 1
    
2.
Avasthi R, Mohanty D, Chaudhary SC, Mishra K. Disseminated tuberculosis: Interesting hematological observations. J Assoc Physicians India 2010;58:243-4.  Back to cited text no. 2
    
3.
Kalra A, Kalra A, Palaniswamy C, Vikram N, Khilnani GC, Sood R, et al. Immune thrombocytopenia in a challenging case of disseminated tuberculosis: A case report and review of the literature. Case Rep Med 2010;2010. pii: 946278.  Back to cited text no. 3
    
4.
Tabarsi P, Merza MA, Marjani M. Active pulmonary tuberculosis manifesting with idiopathic thrombocytopenic purpura: A rare presentation. Braz J Infect Dis 2010;14:639-40.  Back to cited text no. 4
    
5.
Dagaonkar RS, Udwadia ZF. Disseminated tuberculosis with immune thrombocytopenic purpura. Lung India 2012;29:63-5.  Back to cited text no. 5
  [Full text]  
6.
Mori M, Sugahara H, Fujikawa T, Inoue T, Sugano T, Kagami S, et al. A case of pulmonary tuberculosis accompanied with immune thrombocytopenic purpura. Respir Med CME 2010;3:232-4.  Back to cited text no. 6
    
7.
Bairagya TD, Das SK, Jana PK, Bhattacharya S. Immune thrombocytopenic purpura associated with pulmonary tuberculosis. J Glob Infect Dis 2012;4:175-7.  Back to cited text no. 7
    
8.
Levy M, Cooper BA. Thrombocytopenic purpura associated with tuberculous lymphadenitis. Can Med Assoc J 1964;90:373-4.  Back to cited text no. 8
    
9.
Talbot S, Dowling A, Dowling JP, Fuller A, Schwarz M. Mediastinal nodal tuberculosis presenting as immune thrombocytopenia. Aust N Z J Med 1998;28:465-6.  Back to cited text no. 9
    
10.
Lu H, Wang YR, Ji O, Xu W, Zhang JF, Fan QH, et al. Supraclavicular lymph node tuberculosis presenting with immune thrombocytopenic purpura. Chin Med J (Engl) 2007;120:1730-1.  Back to cited text no. 10
    


    Figures

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