A 29-year-old man presented with gingival bleeding, hematuria, and a petechial rash. ... He reported tobacco and occasional cocaine use, and denied medications, ... thrombocytopenia, HIV-negative CD4-lymphopenia, and anemia consistent ...
Patolla HR, Miller AC. Pulmonary Mycobacterium Tuberculosis Associated Immune Thrombocytopenia. American Journal of Respiratory and Critical Care Medicine. May 2015:191(9);A3256. Presented at the American Thoracic Society (ATS) 2015 International Conference. Denver, CO. May 2015.
Pulmonary Mycobacterium tuberculosis Associated Immune Thrombocytopenia Purpura. Harish R. Patlolla, MD,1 Andrew C. Miller, MD 2,3,4 1
Department of Medicine, Mount Sinai Hospital. Chicago, IL. Critical Care Medicine Department, Clinical Center, National Institutes of Health. Bethesda, MD. 2 Laboratory of Molecular Biology, National Cancer Institute, National Institutes of Health. Bethesda, MD. 3 Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center. Pittsburgh, PA.
Case Presentation A 29-year-old man presented with gingival bleeding, hematuria, and a petechial rash. He reported 24-pound weight loss over 2-months with increased weakness, dizziness, vague abdominal discomfort, lower-extremity paresthesias and cramping, night-sweats, shortness-of-breath and diminished exercise tolerance. He also noted 1-year of intermittent malaise, subjective fever, and non-productive cough. Recent HIV testing was negative. He reported tobacco and occasional cocaine use, and denied medications, family history of malignancy or bleeding diathesis, or significant occupational exposure. He denied sick contacts, Mycobacterum tuberculosis (MTB) exposure, incarceration, or military experience. Exam was significant for heart rate of 116/min, temperature 38.1˚C, but otherwise normal vital signs. Patient had generalized petechia without mucocutaneous bleeding. Mild cervical and supraclavicular lymphadenopathy was present. Lungs fields were clear, heart sounds normal, and no hepato-splenomegaly was evident. Pertinent laboratory values are listed in Table 1. Notably, patient demonstrated severe thrombocytopenia, HIV-negative CD4-lymphopenia, and anemia consistent with chronic inflammation. Peripheral smear revealed absence of platelets and normal cell morphology. Coagulation studies were normal. Serum lactate dehydrogenase (LDH) and acute phase reactants were elevated.
Chest X-ray revealed ill-defined bilateral hilar opacities (Figure 1). Chest CT identified diffuse ill-defined parenchymal and sub-pleural opacities, and bilateral supraclavicular and mediastinal lymphadenopathy. Immune thrombocytopenia purpura (ITP) treatment was initiated with intravenous (IV) corticosteroids and IV immune globulin (IVIG). Bone marrow biopsy was performed (Table 2). Subsequent mediastinoscopy with lymph node biopsy was complicated by massive hemothorax. Emergent thoracotomy achieved hemostasis, and intra-operative left upper-lobe biopsy was obtained. Scaline lymph node biopsy yielded necrotizing granulomata (Figure 2), and wedge biopsy revealed acid-fast bacilli (Figure 3). He was treated with isoniazid, rifampin, pyrazinamide, and ethambutol for MTB. He remains clinically improved and without recurrent thrombocytopenia at 1 year. Discussion ITP secondary to pulmonary Mycobacterium tuberculosis (ITP/MTB) infection is a rare but described condition, however, its course differs from that of typical ITP. ITP typically requires long-standing corticosteroids, often relapses, and may require splenectomy for long-term remission. Conversely, ITP/MTB responds to short-duration corticosteroids followed by anti-tuberculosis therapy without relapse. Of the 16 cases reported, 0 and 1 patients had a known history of MTB or ITP respectively. In each case, thrombocytopenia resolved with MTB treatment. In patients presenting with ITP, lymphadenopathy, and pulmonary infiltrates, underlying MTB should be considered. Lymph node or lung biopsy should be considered to confirm the diagnosis if sputum AFB is negative.
Table 1 Parameter (Reference value) Leukocyte Count (4.5-10.9x103 /microL) Hemoglobin (14-18 g/dL) Hematocrit (Hct) (42-52 %) Platelets (130-400x10-3 /microL) MCV (71.4-94.6 fL) MCHC 30.6 (30.5-35.5 g/dL) Reticulocyte Count (0.5-2.9%) Reticulocyte Index (For Hct 25-35; 1.5) Iron (50-150 mcg/dL) TIBC (250-410 mcg/dL) UIBC (110-370 mcg/dL) Ferritin (22-322 ng/mL) CD4 (544-1894/mm3 ) CD4/CD8 Ratio (0.72-4.02) HIV PT (11.2-13.6 sec) PTT (22.8-29 sec) Fibrinogen (206-488mg/dL)
Value 7.4 8.5 27.7 9 90.2 30.6 2.96 1.16 33 182 149 733.2 248 4.55 Negative 13.5 28.3 5.06
Parameter (Reference value) Na (135-145mmol/L) Potassium (3.5-5 mMol/L) Chloride (101-111 mMol/L) CO2 (24-31 mMol/L) BUN 8-22 mg/dL) Creatinine (0.4-1.2 mg/dL) Glucose (70-99 mg/dL) Calcium (8.4-10.2 mg/dL) Total Protein (6-8.5 g/dL) Albumin (3.3-6.1 g/dL) AST (0-40 IU/L) ALT (0-40 IU/L) Alk Phos (35-145 IU/L) Total Bilirubin (0-1.2 mg/dL) LDH (80-200U/litre) C-Reactive Protein (1-4mg/dL) ACE (8-52U/L) Fibrin Degradation Products
Value 135 4.4 100 27 8 0.83 87 8.4 7.1 3.2 24 24 68 1.4 380 32.8 49 Elevated
Table 2 Specimen Source (Hospital Day #) Sputum & Bronchial Wash Bone Marrow (Day 2)
Scaline Lymph Node (Day 5) Left Upper-Lobe Lung (Day 5)
Pathology Result
5 specimens negative for acid-fast bacilli. Hyper-cellular marrow, myeloid:erythroid ratio 3:1, tri-lineage maturation, normal morphology, and increased megakaryocytes. No granulomata, lymphoma, or fibrosis was observed. Acid-fast and fungal stains were negative. Coalescent necrotizing granulomata.
Coalescent necrotizing granulomata with acid-fast bacilli identified.
