A Case of Immune Thrombocytopenic Purpura Secondary to Pulmonary Tuberculosis

Abstract

A 27-year-old, non-smoker male was admitted to the in-patient Department of Medicine of MKCG Medical College with complaints of intermittent fever not associated with chills and rigor for 8 days, shortness of breath {Medical Research Council (MRC) dyspnoea grade 2}, multiple purpuric spots over chest and extremities, epistaxis, bleeding per rectum, sub-conjunctival bleed and haematuria. There was no history of any haematological disorder, liver disease, cardiovascular disease or any medication intake in the recent past. Physical examinations revealed a temperature of 102°F, and respiratory rate of 28/minute. Blood pressure was 100/60mm Hg, no lymphadenopathy or hepatospleenomegaly. Chest wall examination revealed crepitation over right infra-clavicular area. Perrectal examination revealed no pathology. The electrocardiography was with-in normal limit. The initial complete blood count and routine biochemical parameters were normal [Table/ Fig-1,2]. Direct Coombs test was negative and Fibrin Degradation Product (FDP) was normal. Serum ferritin was 226ng/ml. (normal value 18-270ng/ml). Quantitative Buffy Coat and Immuno-cromatography Test for malarial antigens were negative. Antibodies to Salmonella antigen, Anti-neutrophlic antibody and rheumatoid factor were absent. HIV, Hepatitis B surface Antigen, Anti-Hepatitis C Virus antibody tests were negative. Blood culture was negative. Bone marrow biopsy showed hyper-cellular marrow and normal maturation of myeloid and erythroid precursors. Megakaryocytes were increased in number and had normal morphology. No granulomas, leukemic infiltrate or metastatic deposits were detected. Sputum was positive for Acid Fast Bacilli [AFB] on more than two occasions. A chest x-ray demonstrated patchy opacity over right upper zone [Table/ Fig-3]. Based upon above finding, a provisional diagnosis of pulmonary tuberculosis with thrombocytopenia was made. Patient was then put on Directly Observed Treatment and Short (DOTS) course category-1 Anti-Tuberculosis Therapy (ATT) (i.e., isoniazid 5mg/ kg/d, rifampicin10mg/kg/d, ethambutol 25mg/kg/d, pyrazinamide 30mg/kg/d) and subsequently received 8 units of random donor platelets. However, over a period of next 7 days the platelet counts did not increased satisfactorily and the petechiae and purpura were remained as before. In view of low platelet count oral prednisone (1mg/kg/day) was started along with ATT. By judging the clinical severity and patient's affordability for human immunoglobulin in a resource limited setting like our institution, we had preferred prednisolone as a primary therapy.Platelets count started to increase after two weeks of the ATT and prednisone. There was no fresh bleeding from any sites, petechiae and purpura started to decrease. Prednisone was then tapered off over a period of one month. Patient was followed-up every month for first 6 months and there was no recurrence of thrombocytopenia. Sputum AFB was negative at 2 nd and 6 th months of follow-up. Platelet counts were 1.54lacs/Cumm, 2.24lacs/Cumm at first and sec...

Assessment of Haematological Parameters of Pulmonary Tuberculosis Patients with and Without HIV Infection Attending Two Secondary Health Facilities in Jigawa State

“…The prevalence of thrombocytopenia among PTB patients was 20.00% while it was 14.29% among PTB/HIV coinfected patients. Different mechanisms such as immune mechanisms, bone marrow fibrosis, direct megakaryocyte infection, and hypersplenism had been implicated as possible causal factors for thrombocytopenia in PTB/HIV co-infected patients [27].…”

Immune Thrombocytopenic Purpura Secondary to Peritoneal Tuberculosis Patient with Anti-Tuberculosis Drug-Induced Liver Injury. A Case Report

“…ITP is further differentiated into primary ITP or secondary ITP (6). Common secondary causes of ITP include autoimmune diseases like SLE, infections (HIV/hepatitis C), drugs (rifampicin), and lymphoproliferative disorders but tuberculosis per se is a very rare condition (8).…”

A case of immune thrombocytopenia due to miliary tuberculosis effectively treated with eltrombopag

“…Weber et al concluded that early diagnosis and initiation of treatment for tuberculosis should be given the highest priority to reduce the use of immunosuppressants, transfusion, and the risk of hemorrhage [ 1 ]. There are 4 new case reports of ITP due to tuberculosis after Weber's report [ [4] , [5] , [6] , [7] ]. Considering 50 cases and 4 cases, most cases obtain platelets response using anti-tuberculosis treatment, corticosteroid and IVIG.…”

“…Time from treatment initiation until platelets recovery varies from some days to a few months. No severe fetal bleeding occurred in the clinical course [ 1 , [4] , [5] , [6] , [7] ].…”

“…A low dose of prednisolone may be one of the reasons that anti-tuberculosis treatment and prednisolone were not effective for ITP due to tuberculosis. In adults with newly diagnosed ITP, the ASH guideline panel suggests either prednisone (0.5–2.0 mg/kg per day) or dexamethasone (40 mg per day for 4 days) as the corticosteroid for initial therapy [ 6 ]. In the treatment of secondary ITP due to tuberculosis, the most important aim is curing tuberculosis.…”