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Uryu H, Nakamura T, Nakashima D, Yamamoto K, Honda Y, Ishikawa M, Tsujita T, Hata N, Oinuma T, Yamazaki H, Yahagi Y. Miliary tuberculosis-associated hemophagocytic lymphohistiocytosis with a high level of soluble interleukin-2 receptor successfully treated with concomitant recombinant thrombomodulin: A case report. J Infect Chemother 2023; 29:361-366. [PMID: 36481565 DOI: 10.1016/j.jiac.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/30/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a fatal disease characterized by a highly inflammatory state due to the abnormal activation of T lymphocytes and macrophages. Miliary tuberculosis (MTB) is a rare cause of HLH and its clinical appearances occasionally resembles that of intravascular lymphoma (IVL). A 76-year-old woman presented with persistent fever and fatigue. Abnormal laboratory findings showing thrombocytopenia (13,000/μL), hypofibrinogenemia (101 mg/dL), hyperferritinemia (2,312 ng/mL), and markedly elevated soluble interleukin-2 receptor (sIL-2R) level (32,200 U/mL), in addition, hemophagocytosis in the bone marrow (BM) smear, were suggestive of IVL-associated HLH. The pathology of the BM biopsy specimen showed granuloma with non-caseous necrosis, and culture tests using sputum, gastric fluid, urine, and peripheral and bone marrow blood revealed the presence of Mycobacterium tuberculosis, leading to the final diagnosis of MTB-associated HLH. Anti-TB medications and corticosteroids were administered, but thrombocytopenia, hypofibrinogenemia, and hyperferritinemia persisted. Concomitant use of recombinant thrombomodulin (rTM) enabled regression of clinical status. In this case, BM biopsy served as the diagnosis of MTB-associated HLH, although IVL-associated HLH is initially suspected by an extremely high level of sIL-2R. Furthermore, this case report informs that using rTM could improve the outcomes of MTB-associated HLH.
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Affiliation(s)
- Hideki Uryu
- Department of Hematology, Kawaguchi Municipal Medical Center, Saitama, Japan.
| | - Takashi Nakamura
- Department of Hematology, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Daisuke Nakashima
- Department of Nephrology, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Kazuyoshi Yamamoto
- Department of Nephrology, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Yu Honda
- Department of Nephrology, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Masahiro Ishikawa
- Department of Nephrology, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Tomohiro Tsujita
- Department of Respiratory Medicine, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Norihiko Hata
- Department of Respiratory Medicine, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Toshinori Oinuma
- Department of Pathology, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Hiroyuki Yamazaki
- Department of Hematology, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Yuichi Yahagi
- Department of Hematology, Kawaguchi Municipal Medical Center, Saitama, Japan
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