Extrapulmonary tuberculosis is often a diagnostic challenge. Rarer manifestations of tuberculosis should be considered especially in case of persistent fever and in the presence of patients from high-incidence countries. Rapid diagnosis and timely treatment are decisive elements for the prognosis of patients. This is underlined by pulmonologist Arne Lüers of the Asklepios Klinikum Harburg Hospital in Hamburg.The reason is the story of a 37-year-old man, which he describes in the «Deutsche Medizinische Wochenschrift».
The patient and his story
As the pulmonologist recounts, the 37-year-old patient from India presented with a fever that had persisted for four weeks, accompanied by night sweats and a weight loss of three kilograms. The fever had not responded to , however repeated administration of ibuprofen was effective. No previous diseases had been found, apart from obesity.
The first investigations
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Chest X-ray: evident bilateral right mass.
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Chest CT: Fusion tumor, surrounding the central vessels and the right main bronchus.
Chest X-ray: evident bilateral right mass.
Chest CT: Fusion tumor, surrounding the central vessels and the right main bronchus.
Course, further findings and a suspicion
Immediately after hospitalization, in addition to the persistence of high fever, mucous bleeding and mild hemoptysis occurred.Laboratory diagnosis showed a decrease in platelets to 4/nl.
After further laboratory diagnosis and the exclusion of possible differential diagnoses, drug-induced thrombocytopenia (drug-induced immune thrombocytopaenia, DITP) arose. The drug was then discontinued. Due to fever and bleeding, the patient was given platelet concentrates several times.
Diagnosis and therapy
For further clarification, the thoracic mass was biopsied. Tissue examination revealed tuberculosis of the lymph nodes, confirmed by microscopic examination.
Based on these results, doctors in Hamburg started anti-tuberculosis therapy with a combination of four drugs, which however was stopped after four days because liver transaminase values, already slightly elevated at the beginning, continued to rise.
Due to the severity of hepatitis and persistently elevated bilirubin values, therapy was changed from rifampicin to levofloxacin.This led to a decrease in fever. Due to the high suspicion of DITP, prednisolone therapy was initiated. A bone marrow biopsy to rule out hemophagocytosis syndrome or a clotting disorder revealed a pronounced finding of «bone marrow infiltration by granulomas to partially necrotizing epithelioid cells.» In staining with Auramine, individual acidophilic bacilli were detected.
Under antituberculosis therapy and prednisolone, the patient’s condition improved and he was discharged for further outpatient treatment.
Talk
As explained by the pulmonologist, the diagnosis of «lymph node tuberculosis» was delayed due to the rare complication of drug-induced thrombocytopenia, which may have induced a delayed response to prednisolone and been associated with worsening conditions.
A pronounced infiltration of the bone marrow by tuberculosis had been declared as an incidental finding.According to the pulmonologist, bone marrow infiltration has been described in miliary tuberculosis and may be accompanied by pancytopenia. In an Indian study, a frequent finding in the blood count of patients with disseminated tuberculosis was thrombocytopenia and, in case of established bone marrow infiltration or detection of granulomas, the finding of severe anaemia.
Tuberculosis patients can usually be treated with a well-tolerated standard 4-drug therapy in the absence of antibiotic resistance. The probability of curing tuberculosis is currently 85% globally. However, while the overall incidence decreases in Europe, there is a high proportion of patients with multidrug-resistant tuberculosis (especially in Eastern Europe). In addition, an increase in liver enzymes during therapy is common.
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