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CASE REPORT
Year : 2019  |  Volume : 44  |  Issue : 3  |  Page : 190-192

Immune thrombocytopenic purpura and tuberculosis: a rare association with management implications


Department of General Medicine, M.E.S. Medical College, Perinthalmanna, Kerala, India

Date of Submission21-Feb-2019
Date of Acceptance24-Apr-2019
Date of Web Publication05-Dec-2019

Correspondence Address:
Cherumkuzhiyil Abdulla Mansoor
Department of General Medicine, M.E.S. Medical College, Perinthalmanna, Kerala 679338
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejh.ejh_8_19

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  Abstract 


Immune thrombocytopenia is a rare hematological manifestation associated with tuberculosis (TB). A 68-year-old postmenopausal woman was admitted to our hospital with fever and headache for 3 months and lower limb petechial rash since 1 day. She was evaluated and diagnosed to have central nervous system TB. She also had isolated thrombocytopenia and elevated platelet-associated IgG antibodies with a normal bone marrow study. Steroids combined with anti-TB drugs corrected thrombocytopenia and cured TB. We describe a rare hematological manifestation associated with TB and its management to make the readers aware of such unusual presentations of TB.

Keywords: central nervous system tuberculosis, hematological manifestation, immune thrombocytopenia


How to cite this article:
Mansoor CA. Immune thrombocytopenic purpura and tuberculosis: a rare association with management implications. Egypt J Haematol 2019;44:190-2

How to cite this URL:
Mansoor CA. Immune thrombocytopenic purpura and tuberculosis: a rare association with management implications. Egypt J Haematol [serial online] 2019 [cited 2020 Jan 19];44:190-2. Available from: http://www.ehj.eg.net/text.asp?2019/44/3/190/272373




  Introduction Top


Hematological manifestations of tuberculosis (TB) include anemia, leukocytosis, leukopenia, thrombocytosis, or thrombocytopenia. Thrombocytosis is commonly seen in pulmonary TB whereas thrombocytopenia is common in miliary TB. Thrombocytopenia in TB can be secondary to various mechanisms. Bone marrow infiltration, histiophagocytosis, thrombotic thrombocytopenic purpura, disseminated intravascular coagulation, and immune-mediated platelet destruction are the possible causes.


  Case history Top


A 68-year-old postmenopausal woman was admitted to our hospital with fever and throbbing right-sided headache for 3 months and lower limb petechial rash since 1 day. She had no history of significant weight loss, had no sick contacts, and had no history of addictions. She had diabetes mellitus and systemic hypertension for 6 years and was on regular medications. She had palpable apical group of axillary lymph node of 2×2 cm (nonmobile, nontender), petechiae over both lower limbs and echymotic patches over both the upper limbs. She had no other bleeding manifestations. She had no focal neurological deficits and papilledema. Hemoglobin was 13.8 g/dl, total leukocyte count 5100/ml with a normal differential, platelet count of 8000/μl, and erythrocyte sedimentation rate of 47 mm in 1 h. The peripheral smear showed severe thrombocytopenia. The coagulation profiles including prothrombin time, activated partial thromboplastin time, fibrinogen, and fibrin degradation product were within normal limits. Blood chemistries were normal. The serum platelet-associated IgG levels were elevated. MRI of the brain showed multiple ring enhancing lesions with moderate perilesional edema in the cortex, thalamus, and the cerebellum with contrast enhancement and multiple contrast-enhancing intramedullary spinal cord lesions ([Figure 1]a, d, arrow). Purified protein derivative test showed 14 mm induration. Histopathology from the lymph node showed caseating granuloma ([Figure 2]) and the mycobacterial cultures showed growth of mycobacterium TB. Ultrasound of the abdomen was normal. Bone marrow aspirate and biopsy showed normocellular marrow with normal maturation of erythroid and myeloid precursors. Megakaryocytes were normal in both number and morphology, and there was no granuloma. Hepatitis B virus, hepatitis C virus, HIV serologies, and antinuclear antibodies were negative. She was diagnosed as having central nervous system TB with possible immune thrombocytopenic purpura and was started on isoniazid, ethambutol, pyrazinamide, and rifampicin. She also received 1 g of intravenous methylprednisolone for 3 days followed by 60 mg of oral prednisolone once daily which was tapered slowly. When followed up she was asymptomatic, had radiological improvement, and had normal platelet count.
Figure 1 Magnetic resonance imaging of brain showing multiple ring enhancing lesions with moderate perilesional oedema in the cortex (arrow 1a), thalamus (arrow 1b) and cerebellum (arrow 1c) and multiple contrast enhancing intramedullary spinal cord lesions (arrow 1d).

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Figure 2 Histopathology of the lymph node showing caseating granuloma (Hematoxylin and Eosin staining, ×40).

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  Discussion Top


Hematological abnormalities are common in TB and isolated thrombocytopenia has been reported in 23–43% of patients with disseminated TB, but isolated thrombocytopenia caused by an immune mechanism is an extremely rare manifestation [1]. The mechanisms leading to TB-related immune thrombocytopenia is not well described. Antiplatelet antibodies produced by the activation of B-lymphocytes by mycobacterium TB or mycobacterium TB sharing the antigen with platelets leading to antiplatelet antibody are the possible mechanisms [2]. TB infection stimulates suppressor monocyte activity together with reduction of T-lymphocytes and purified protein derivative of tuberculin may be a nonspecific B-lymphocyte stimulator.

Our patient was admitted with multiple cerebral ring enhancing lesions and was diagnosed to have central nervous system TB. She had severe thrombocytopenia probably secondary to immune-mediated destruction, evidenced by normal megakaryocyte count in the bone marrow, positive antiplatelet antibodies, and good response to steroid therapy. Other infective and autoimmune causes were ruled out by appropriate tests. Our patient had yet other rare manifestations including intramedullary tuberculoma. Spinal intramedullary tuberculoma is rare, accounting for 2/100 000 of cases of TB and only 2% of all cases of TB of the central nervous system [3]. Lymph node biopsy was difficult in our patient due to severe thrombocytopenia but was necessary to make a proper diagnosis. A fine-needle aspiration cytology in our patient showed only reactive changes. The two important differential diagnosis in our patient considering the clinical and radiological features were lymphoma and TB. A definitive etiological diagnosis was crucial for proper treatment which was only possible with a lymph node biopsy. Review of previous literature showed that there were similar instances where a lymph node biopsy was performed in patients with severe thrombocytopenia [4].

TB -related immune thrombocytopenia was previously reported in association with pulmonary TB, lymphadenitis, and miliary TB. Most of the cases were treated with anti-TB drugs, combined with corticosteroid, immunoglobulin, or vincristine with a good outcome [5],[6],[7],[8]. Central nervous system TB presenting with immune thrombocytopenia was not previously reported.

We describe a rare association of central nervous system TB with immune thrombocytopenia and discuss the diagnostic challenges and management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tsuro K, Kojima H, Mitoro A, Yoshiji H, Fujimoto M, Uemura M et al. Immune thrombocytopenic purpura associated with pulmonary tuberculosis. Inter Med 2006; 45:739–742.  Back to cited text no. 1
    
2.
Srividya G, Nikhila GP, Kaushik AV, Jayachandran K. Immune thrombocytopenia in tuberculosis: causal or coincidental?. J Glob Infect Dis 2014; 6:128.  Back to cited text no. 2
    
3.
Lu M. Imaging diagnosis of spinal intramedullary tuberculoma: case reports and literature review. J Spinal Cord Med 2010; 33:159–162.  Back to cited text no. 3
    
4.
Wu X, Zhao G. Thrombocytopenia should not be barrier for lymph-node biopsy. Int J Hematol Oncol 2016; 26:220–223.  Back to cited text no. 4
    
5.
Spedini P. Tuberculosis presenting as immune thrombocytopenicpurpura. Haematologica 2002; 87:FLT09.  Back to cited text no. 5
    
6.
Tongyoo S, Vilaichone W, Sukpanichnant S, Auewarakul C, Chaiprasert A, Ratanarat R, Permpikul C. Thrombocytopenic purpura associated with miliary tuberculosis. J Med Assoc Thai 2003; 86:976–980.  Back to cited text no. 6
    
7.
Bakhshi S, Kabra M, Iyer VK, Arya LS. Thrombocytopenic purpuraas a presenting manifestation of tubercular lymphadenitis. Indian J Pediatr 2003; 70:993–994.  Back to cited text no. 7
    
8.
Ozkalemkas F, Ali R, Ozkan A, Ozcelik O, Ozkocaman V, Kunt-Uzaslan E, Bahadir-Erdogan B, Akalin H. Tuberculosis presenting as immune thrombocytopenic purpura. Ann Clin Microbiol Antimicrob 2004; 3:16.  Back to cited text no. 8
    


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