A 63-year-old man presented to the emergency room with complaints of fever, dyspnea, and confusion. He has a history of chronic obstructive pulmonary disease (COPD).
The patient fatigue, anorexia, and weight loss of 6.8 kg for the past 6 months, but no history of cough, hemoptysis, or recent travel. During this time, he was being treated as COPD exacerbation and pneumonia.
On examination, the patient’s temperature had a body temperature of 39.3°C, the respiratory rate of 32 breaths per minute, and oxygen saturation of 91% on supplemental oxygen.
Serology reveals a platelet count of 99,000 per cubic millimeter (reference range, 160,000 to 370,000) and a ferritin level of 17,189 ng per milliliter (reference range, 22 to 275).
CT chest showed bilateral pulmonary opacities, but no signs of nodularity or cavitation. Sputum gram staining and sputum cultures were negative. Blood cultures were also negative. Interferon-gamma release assay was indeterminate. A bone marrow biopsy was performed, which revealed hemophagocytosis (Panel A; Wright–Giemsa stain) and noncaseating granulomas with acid-fast bacilli (Panel B, arrow; Ziehl–Neelsen stain).
DNA probing of bone marrow aspirate and sputum identified Mycobacterium tuberculosis.
A diagnosis of hemophagocytic lymphohistiocytosis (HLH) associated with disseminated tuberculosis was made.
The patient was shifted to the intensive care unit (ICU) with airborne precautions. Treatment was initiated with antituberculosis drugs.
Unfortunately, the patient died 55 days after the presentation.
Hemophagocytic lymphohistiocytosis is a rare condition in which the patient’s body develops excessive numbers of activated lymphocytes and macrophages. Patients usually present with cytopenias, infections, fever, neurological features, and organomegaly.
The treatment depends on several factors. Efforts are made to treat the underlying disease. When associated with tuberculosis, early initiation of ATT helps to reduce the morbidity and mortality.
References
Michael Kessler, M. a. (2020, April 30). HLH Associated with Disseminated Tuberculosis. Retrieved from The New England Journal of Medicine: https://www.nejm.org/doi/full/10.1056/NEJMicm1910558
Padhi S, Ravichandran K, Sahoo J, Varghese RG, Basheer A. Hemophagocytic lymphohistiocytosis: An unusual complication in disseminated Mycobacterium tuberculosis. Lung India. 2015;32(6):593‐601. doi:10.4103/0970-2113.168100
