Tuberc Respir Dis.  2008 Dec;65(6):522-526.

A Case of Tuberculosis-associated Hemophagocytic Syndrome during Antituberculosis Medication for Tuberculous Pericarditis

• No JH
• Kang JY
• Lee BH
• Kim YJ
• Lee JE
• Min JS
• Kang MK
• Kim KH
• Yoon HK
• Song JS

Abstract

A 63-year old woman was admitted to our hospital for an evaluation of thrombocytopenia. She had been diagnosed with tuberculous pericarditis three months earlier in a local clinic and treated with anti-tuberculosis medication. Two months later, thrombocytopenia developed. The medication was subsequently stopped because it was suspected that the anti-tuberculosis medication, particularly rifampin, might have caused the severe platelet reduction. However, the thrombocytopenia was more aggravated. A bone marrow biopsy was performed, which showed moderate amounts of histiocytes with active hemophagocytosis. This finding strongly suggested that the critical thrombocytopenia had been caused by hemophagocytic syndrome, not by the side effects of the anti-tuberculosis medication. Furthermore, the development of hemophagocytosis might have been due to an uncontrolled tuberculosis infection and its associated aberrant immunity. Therefore, she was started with both standard anti-tuberculosis medication and chemotherapy using etoposide plus steroid. One month after the initiation of treatment, the thrombocytopenia had gradually improved and she was discharged in a tolerable condition. At the third month of the follow-up, her platelet level and ferritin, the activity marker of hemophagocytic syndrome, was within the normal range.

Keyword

Hemophagocytic syndrome; Tuberculosis pericarditis; Antituberculosis medication

MeSH Terms

Biopsy
Blood Platelets
Bone Marrow
Etoposide
Female
Ferritins
Follow-Up Studies
Histiocytes
Humans
Lymphohistiocytosis, Hemophagocytic
Pericarditis, Tuberculous
Reference Values
Rifampin
Thrombocytopenia
Tuberculosis
Etoposide
Ferritins
Rifampin

Figure

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  Figure 1 Chest X-ray shows mild cardiomegaly.

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  Figure 2 Echocardiogram shows focal calcification of the pericardium, which was possibly caused by tuberculous pericarditis.

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  Figure 3 Bone marrow aspirate reveals histiocytes showing active hemophagocytosis (H&E stain, ×1,000).

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  Figure 4 Platelet count was minimally improved, even though antituberculous medication and high dose steroid (1 mg/kg) were started at the time when the patient was diagnosed with tuberculosis-associated hemophagocytic syndrome (4th hospital day). After substituting steroid to chemotherapy which consisted of etoposide and steroid on the 14th hospital day, platelet count was increased and serum ferritin level was decreased within the normal range.

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