A 63-year-old Man With Disseminated Tuberculosis

Image Source: The New England Journal of Medicine©

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.


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

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Dr. Arsia Hanif has been a meritorious Healthcare professional with a proven track record throughout her academic life securing first position in her MCAT examination and then, in 2017, she successfully completed her Bachelors of Medicine and Surgery from Dow University of Health Sciences. She has had the opportunity to apply her theoretical knowledge to the real-life scenarios, as a House Officer (HO) serving at Civil Hospital. Whilst working at the Civil Hospital, she discovered that nothing satisfies her more than helping other humans in need and since then has made a commitment to implement her expertise in the field of medicine to cure the sick and regain the state of health and well-being. Being a Doctor is exactly what you’d think it’s like. She is the colleague at work that everyone wants to know but nobody wants to be. If you want to get something done, you approach her – everyone knows that! She is currently studying with Medical Council of Canada and aspires to be a leading Neurologist someday. Alongside, she has taken up medical writing to exercise her skills of delivering comprehensible version of the otherwise difficult medical literature. Her breaks comprise either of swimming, volunteering services at a Medical Camp or spending time with family.


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