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Yadav KSK, Agrawal AK, Biswal SR, Panda P, Panda PK, Sharawat IK. Pancytopenia without Hepatosplenomegaly: A Rare Manifestation of Extrapulmonary Tuberculosis in an Adolescent Boy. Adv Biomed Res 2020; 9:75. [PMID: 33912491 PMCID: PMC8059450 DOI: 10.4103/abr.abr_170_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 07/29/2020] [Accepted: 09/08/2020] [Indexed: 11/04/2022] Open
Abstract
Extrapulmonary tuberculosis (TB) is a well-recognized cause of pyrexia of unknown origin. However, clinical presentation of TB in children with isolated hematological abnormalities is extremely rare. Anemia, usually normocytic, normochromic, leukopenia, leukocytosis, thrombocytopenia, thrombocytosis, and monocytosis are more common complications of TB rather than pancytopenia. Only anecdotal case reports and small case series are available in this regard. We are reporting an 18-year-old boy who presented with on and off low-grade fever for 3 months and anorexia and progressive pallor for 1 month. After extensive workup, pancytopenia remained unexplained. Bone marrow (BM) examination revealed caseating granulomas, along with Mantoux positivity and contact with sputum-positive pulmonary TB. He responded favorably to antitubercular therapy (ATT) within 2 months. This report alerts clinicians to be vigilant regarding the rare possibility of BM TB while investigating unexplained pancytopenia, as it is completely reversible with ATT.
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Affiliation(s)
- K Sushrith Kumar Yadav
- Department of Pediatrics, Kalinga Institute of Medical Sciences, Bhubaneshwar, Odisha, India
| | - Aman Kumar Agrawal
- Department of Pediatrics, Kalinga Institute of Medical Sciences, Bhubaneshwar, Odisha, India
| | - Seba Ranjan Biswal
- Department of Pediatrics, Kalinga Institute of Medical Sciences, Bhubaneshwar, Odisha, India
| | - Pragnya Panda
- Department of Medicine, SCB Medical College, Cuttack, Odisha, India
| | - Prateek Kumar Panda
- Department of Pediatrics, Pediatric Neurology Division, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Indar Kumar Sharawat
- Department of Pediatrics, Pediatric Neurology Division, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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Swami V, Lalitha AV, Anjan Kumar TK. Tuberculosis and Tumor Lysis Syndrome-Coincidence or Coexistent: A Case Report. Indian J Crit Care Med 2020; 24:145-147. [PMID: 32205951 PMCID: PMC7075064 DOI: 10.5005/jp-journals-10071-23359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Extrapulmonary tuberculosis (TB) involving bone marrow can present with various manifestations, including pancytopenia, maturation arrest, hemophagocytic lymphohistiocytosis (HLH), or infiltration of the bone marrow by caseating or noncaseating granulomas causing reversible or irreversible fibrosis. Tumor lysis syndrome (TLS) is an oncologic emergency resulting from massive tumor cell lysis. Children with TB with bone marrow involvement may also present with laboratory features of TLS resulting from high catabolism and concomitant acute kidney injury (AKI), making the diagnosis difficult at times. We present a case of disseminated TB who presented to emergency with pancytopenia, AKI, and laboratory features of TLS.
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Affiliation(s)
- Viresh Swami
- Department of Pediatric Critical Care, St. John's Medical College, Bengaluru, Karnataka, India
| | - A V Lalitha
- Department of Pediatric Critical Care, St. John's Medical College, Bengaluru, Karnataka, India
| | - T K Anjan Kumar
- Department of Pediatric Critical Care, St. John's Medical College, Bengaluru, Karnataka, India
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Mbizvo GK, Lentell IC, Leen C, Roddie H, Derry CP, Duncan SE, Rannikmäe K. Epilepsia partialis continua complicated by disseminated tuberculosis and hemophagocytic lymphohistiocytosis: a case report. J Med Case Rep 2019; 13:191. [PMID: 31230590 PMCID: PMC6589876 DOI: 10.1186/s13256-019-2092-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 04/18/2019] [Indexed: 11/11/2022] Open
Abstract
Background We describe a patient copresenting with epilepsia partialis continua, tuberculosis, and hemophagocytic lymphohistiocytosis. To our knowledge, this is the first documented case of this triad. Case presentation A 54-year-old black South African woman presented to a hospital in Scotland with an acute history of right-sided facial twitching, breathlessness, and several months of episodic night sweats. Clinical examination revealed pyrexia and continuous, stereotyped, right-sided facial contractions. These worsened with speech and continued through sleep. A clinical diagnosis of epilepsia partialis continua was made, and we provide a video of her seizures. Computed tomographic imaging of the chest and serous fluid analyses were consistent with a diagnosis of disseminated Mycobacterium tuberculosis. An additional diagnosis of hemophagocytic lymphohistiocytosis was made following the identification of pancytopenia and hyperferritinemia in peripheral blood, with hemophagocytosis evident in bone marrow investigation. We provide images of her hematopathology. The patient was extremely unwell and was hospitalized for 6 months, including two admissions to the intensive care unit for ventilatory support. She was treated successfully with high doses of antiepileptic drugs (benzodiazepines, levetiracetam, and phenytoin) and 12 months of oral antituberculosis therapy, and she underwent chemotherapy with 8 weeks of etoposide and dexamethasone for hemophagocytic lymphohistiocytosis, followed by 12 months of cyclosporine and prednisolone. Conclusions This combination of pathologies is unusual, and this case report helps educate clinicians on how such a patient may present and be managed. A lack of evidence surrounding the coexpression of this triad may represent absolute rarity, underdiagnosis, or incomplete case ascertainment due to early death caused by untreated tuberculosis or hemophagocytic lymphohistiocytosis. Further research is needed. Electronic supplementary material The online version of this article (10.1186/s13256-019-2092-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gashirai K Mbizvo
- Muir Maxwell Epilepsy Centre, Centre for Clinical Brain Sciences, The University of Edinburgh, 20 Sylvan Place, Edinburgh, EH9 1UW, UK. .,Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK.
| | - Isabel C Lentell
- Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Clifford Leen
- Regional Infectious Diseases Unit, Western General Hospital, Edinburgh, UK
| | - Huw Roddie
- Department of Haematology, Western General Hospital, Edinburgh, UK
| | - Christopher P Derry
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK.,Department of Clinical Neurosciences and Sleep Medicine, Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Susan E Duncan
- Muir Maxwell Epilepsy Centre, Centre for Clinical Brain Sciences, The University of Edinburgh, 20 Sylvan Place, Edinburgh, EH9 1UW, UK.,Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - Kristiina Rannikmäe
- Forth Valley Royal Hospital, Larbert, and Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
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Tahir M, Nida A, Qamar S. Hiding in the bone: a case of miliary tuberculosis with bone marrow involvement. AME Case Rep 2018; 2:36. [PMID: 30264032 DOI: 10.21037/acr.2018.06.05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 06/04/2018] [Indexed: 11/06/2022]
Abstract
Dissemination of tuberculosis is known as miliary tuberculosis. The clinical features of disseminated tuberculosis often leads to misdiagnosis. By the time we have bone marrow involvement by tuberculosis, prognosis is really poor. Here, we report a case of tuberculosis of the bone marrow causing pancytopenia which reversed after the treatment with anti-tuberculosis regimen. This case highlights the importance of tuberculosis in the diagnosis of pancytopenia in suspected patients.
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Affiliation(s)
- Muhammad Tahir
- Catholic Health System, Internal Medicine, University at Buffalo, NY, USA
| | - Anum Nida
- Catholic Health System, Internal Medicine, University at Buffalo, NY, USA
| | - Sohaib Qamar
- Catholic Health System, Internal Medicine, University at Buffalo, NY, USA
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Dalugama C, Gawarammana IB. Fever with pancytopenia: unusual presentation of extrapulmonary tuberculosis: a case report. J Med Case Rep 2018; 12:58. [PMID: 29506574 PMCID: PMC5838939 DOI: 10.1186/s13256-018-1596-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 01/29/2018] [Indexed: 11/30/2022] Open
Abstract
Background Tuberculosis is a major health problem in the developing world. Diagnosis of extrapulmonary tuberculosis is delayed because the presentation is nonspecific. Extrapulmonary tuberculosis can present with various hematological manifestations, including pancytopenia. Pancytopenia could be due to hypersplenism, maturation arrest, hemophagocytic lymphohistiocytosis, or infiltration of the bone marrow by caseating or noncaseating granulomas causing reversible or irreversible fibrosis. Case presentation We report a case of a 56-year-old Sri Lankan Sinhalese man who presented with pyrexia of known origin with significant loss of weight and loss of appetite. He had mild pallor with mild hepatosplenomegaly. He had high inflammatory markers with pancytopenia in a peripheral blood smear. His chest radiograph was unremarkable, and he had a negative Mantoux test result. A diagnosis of disseminated tuberculosis was made on the basis of caseating tuberculous granulomas in the bone marrow. Conclusions Disseminated tuberculosis remains a diagnostic challenge because the presentation is vague and nonspecific. In case of pyrexia of unknown origin with peripheral cytopenia, the possibility of disseminated tuberculosis should be considered, particularly in endemic areas. Simultaneous culture and histopathological examination of the bone marrow is important in such instances, because results of common tests such as chest radiography or Mantoux tests can be negative.
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Affiliation(s)
- Chamara Dalugama
- Department of Medicine, University of Peradeniya, Peradeniya, Sri Lanka.
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Sharma SK, Mohan A, Sharma A. Miliary tuberculosis: A new look at an old foe. J Clin Tuberc Other Mycobact Dis 2016; 3:13-27. [PMID: 31723681 PMCID: PMC6850233 DOI: 10.1016/j.jctube.2016.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 03/08/2016] [Accepted: 03/10/2016] [Indexed: 11/03/2022] Open
Abstract
Miliary tuberculosis (TB), is a fatal form of disseminated TB characterized by tiny tubercles evident on gross pathology similar to innumerable millet seeds in size and appearance. Global HIV/AIDS pandemic and increasing use of immunosuppressive drugs have altered the epidemiology of miliary TB. Keeping in mind its protean manifestations, clinicians should have a low threshold for suspecting miliary TB. Careful physical examination should focus on identifying organ system involvement early, particularly TB meningitis, as this has therapeutic significance. Fundus examination for detecting choroid tubercles can help in early diagnosis as their presence is pathognomonic of miliary TB. Imaging modalities help in recognizing the miliary pattern, define the extent of organ system involvement and facilitate image guided fine-needle aspiration cytology or biopsy from various organ sites. Sputum or BAL fluid examination, pleural, pericardial, peritoneal fluid and cerebrospinal fluid studies, fine needle aspiration cytology or biopsy of the lymph nodes, needle biopsy of the liver, bone marrow aspiration and biopsy, testing of body fluids must be carried out. GeneXpert MTB/RIF, line probe assay, mycobacterial culture and drug-susceptibility testing must be carried out as appropriate and feasible. Treatment of miliary TB should be started at the earliest as this can be life saving. Response to first-line anti-TB drugs is good. Screening and monitoring for complications like acute respiratory distress syndrome (ARDS), adverse drug reactions like drug-induced liver injury, drug-drug interactions, especially in patients co-infected with HIV/AIDS, are warranted. Sparse data are available from randomized controlled trials regarding optimum regimen and duration of anti-TB treatment.
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Affiliation(s)
- Surendra K Sharma
- Department of Medicine, All India Institute of Medical Sciences, New Delhi 110 029, India
| | - Alladi Mohan
- Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati 517 507, India
| | - Animesh Sharma
- Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110 060, India
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Unusual manifestation of extrapulmonary tuberculosis. Case Rep Med 2013; 2013:353798. [PMID: 23710189 PMCID: PMC3655508 DOI: 10.1155/2013/353798] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 02/05/2013] [Indexed: 11/30/2022] Open
Abstract
Though commonly encountered, extrapulmonary tuberculosis (TB) can sometimes present with variable clinical picture intricating the diagnosis (Avasthi et al., 2010). The nonspecific symptoms include pyrexia of unknown origin, hepatosplenomegaly, lymphadenopathy, meningitis, and, rarely, variety of hematological abnormalities, namely, anemia, pancytopenia, and leukemoid reaction (Avasthi et al., 2010). When it presents with bone marrow (BM) involvement, prognosis is usually poor (Avasthi et al., 2010, Qasim et al., 2003, and Singh et al., 2001). We, hereby, report a case of extra-pulmonary TB with a six-month history of fever associated with dizziness, fatigability, and cough. During the hospital stay, the patient showed a spectrum of interesting hematological findings, including severe pancytopenia on peripheral smear, necrotizing caseating granulomas consistent with TB on bone marrow examination. The patient showed a good clinical as well as hematological response to antituberculosis treatment. This paper highlights the significance of a hematological picture in the final confirmation of TB, which may otherwise be passed off as nutritional or other unrelated causes.
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Achi HV, Ahui BJM, Anon JC, Kouassi BA, Dje-Bi H, Kininlman H. [Pancytopenia: a severe complication of miliary tuberculosis]. Rev Mal Respir 2012; 30:33-7. [PMID: 23318187 DOI: 10.1016/j.rmr.2012.08.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 08/09/2012] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To analyze the epidemiology, clinical features and outcome of patients with hematologic abnormalities in miliary tuberculosis. METHODS This was a retrospective study in the pneumology department of the University hospital in Abidjan (RCI), between January 2000 and December 2009. We analyzed the medical records of patients with pancytopenia occurring in the context of miliary tuberculosis. We compared the clinical characteristics and the outcome in patients with pancytopenia versus patients without pancytopenia. RESULTS Pancytopenia occurred in 12% of patients with miliary tuberculosis; 11 men (61%) and seven women (39%). The average age of patients was 33 years, [17-67 years]. Pancytopenia with miliary tuberculosis was frequently associated with HIV: 92.8% (P=0.0009). The clinical characteristics were: fever (88.9%), severe weight loss: 100% vs. 78.8% MT without pancytopenia (P=0.025), respiratory distress: 100% vs. 52.3% MT without pancytopenia (P=0.00032), splenomegaly: 77.8% vs. 5.30% MT without pancytopenia (P=0.0000), multiple lymph nodes: 66.7% vs. 29.5% MT without pancytopenia (P=0.0043). The occurrence of pancytopenia in military TB is associated with a bad prognosis and the outcome was unfavorable in 8.33% (P=0.00001). CONCLUSION Patients with pancytopenia in miliary tuberculosis have a high mortality despite tuberculosis treatment.
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Affiliation(s)
- H V Achi
- Service de pneumologie, centre hospitalier universitaire de Bouaké, 01 BP, 11981 Abidjan 01, Côte d'Ivoire.
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