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CASE REPORT  
Year : 2012  |  Volume : 4  |  Issue : 3  |  Page : 175-177
Immune thrombocytopenic purpura associated with pulmonary tuberculosis


1 Department of Tuberculosis and Respiratory diseases, North Bengal Medical College, Sushratanagar, Darjeeling, India
2 Department of Tuberculosis and Respiratory diseases, Medical College, Kolkata, India
3 Department of Tuberculosis and Respiratory diseases, Institute of Postgraduate Medical Education and Research, Kolkata, India
4 Department of Tuberculosis and Respiratory diseases, R.G. Kar Medical College, Kolkata, West Bengal, India

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Date of Web Publication4-Sep-2012
 

   Abstract 

Thrombocytopenic purpura as a manifestation of pulmonary tuberculosis is very rare. We report a case of 25-year-old female who presented with thrombocytopenia-induced purpuric spots and an abnormal chest X-ray. There was no hepatosplenomegaly while the bone marrow examination revealed normal maturation of myeloid and erythroid series with increased megakaryocytes. Acid fast bacilli were seen in the sputum microscopy. A diagnosis of sputum smear positive pulmonary tuberculosis along with immune thrombocytopenia was made. High dose intravenous immunoglobulin therapy along with antituberculous drugs corrected the thrombocytopenia and also cured pulmonary tuberculosis. This case report illustrates the causal association between immune thrombocytopenia and tuberculosis.

Keywords: Immune thrombocytopenia, Pulmonary tuberculosis, Purpura

How to cite this article:
Bairagya TD, Das SK, Jana PK, Bhattacharya S. Immune thrombocytopenic purpura associated with pulmonary tuberculosis. J Global Infect Dis 2012;4:175-7

How to cite this URL:
Bairagya TD, Das SK, Jana PK, Bhattacharya S. Immune thrombocytopenic purpura associated with pulmonary tuberculosis. J Global Infect Dis [serial online] 2012 [cited 2019 Sep 17];4:175-7. Available from: http://www.jgid.org/text.asp?2012/4/3/175/100580



   Introduction Top


A myriad of hematological abnormalities have been reported in association with tuberculosis (TB) such as anemia, leucocytosis, and pancytopenia. [1] Thrombocytopenia occurring in association with TB is often induced by antituberculous drugs. [2] It can also occur via non-immunogenic means in the context of pancytopenia that develops secondary to granulomatous infiltration of the bone marrow. A causal association between TB and immune thrombocytopenia is extremely rare. We report a case of pulmonary TB with immune thrombocytopenia as the presenting manifestation. High dose immunoglobulin and antituberculous drugs corrected the thrombocytopenia rapidly and also cured pulmonary TB.


   Case Report Top


A 25-year-old previously healthy, non-smoker female was admitted in our hospital with history of fever and productive cough for 1 month and purpuric spots over all limbs for last 2 weeks. There was no history of arthralgia and weight loss. She was not on any medication at the time of admission. Past history and family history were non-contributory. On physical examination, she was alert and well-nourished. Her blood pressure was 110/82 mm Hg, pulse rate 100 beats/min; respiratory rate 20 breaths/ min and oral temperature 38.0°C. She had non-tender, non-palpable purpuric spots over the all 4 limbs [Figure 1]. She had no pallor, sternal tenderness or mucosal bleeding. There was no hepatosplenomegaly or lymphadenopathy. Occasional coarse inspiratory crepitations were heard over the left infraclavicular area. Initial investigations revealed Hb- 9.2 g/dL with MCV- 78.9fl, WBC count 10,400/ mm 3 with 68% neutrophils, 30% lymphocytes, and 2% eosinophils. Platelet count was 36,000/mm 3 and ESR 90 mm/1 st hour. Peripheral blood smear was remarkable for paucity of platelets. Hemoglobin electrophoresis was normal. Bone marrow biopsy revealed a cellular marrow with normal maturation of myeloid and erythroid series. Megakaryocytes were increased in number with normal morphology. No granuloma was detected. Bone marrow culture for Mycobacterium tuberculosis was negative. Coagulation profile and blood biochemistry were normal. Antinuclear factor and Rheumatoid factor were negative. Serology for an HIV was non-reactive. Sputum smear microscopy was positive for acid fast bacilli (AFB). Chest radiograph revealed an infiltration in the left upper zone [Figure 2].
Figure 1: Showing purpuric spots in the upper limb

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Figure 2: Chest X Ray (PA) showing infiltration in the left upper zone

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From these clinical, microbiological, hematological, and radiological findings, she was diagnosed to be having immune thrombocytopenia along with new sputum smear positive pulmonary TB. She was put on WHO Category-I antituberculous drugs with isoniazid, rifampicin, pyrazinamide and ethambutol. High dose intravenous immunoglobulin (IVIG) infusion (0.5 g/kg/day) was started on day 1 and continued for total 5 days. The platelet count normalized on 3 rd day [Figure 3] and remained normal during the course of treatment. Sputum smear was negative for AFB at the end of 2 nd , 4 th and 6 th month of chemotherapy. Thrombocytopenia did not recur during follow-up for 1 year after completion of chemotherapy.
Figure 3: Normalization of platelet count following therapy

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   Discussion Top


Thrombocytopenia in TB is usually a complication of therapy with antituberculous drugs like rifampicin, ethambutol, and pyrazinamide. [2] However, many mechanisms specific for the disease itself can produce thrombocytopenia. Bone marrow changes like fibrosis, granulomatosis, amyloidosis, and necrosis can cause thrombocytopenia along with decrease in other cell lines. [1],[3] Other causes of non-immune thrombocytopenia in association with tuberculosis include hypersplenism, [4] intravascular coagulation, [5] thrombotic thrombocytopenic purpura [6] and hemophagocytic syndrome. [7]

Immune thrombocytopenia in association with or as a presenting manifestation of TB is very rare. Though usually reported in association with pulmonary TB, [8] it is also documented with mediastinal, [9] disseminated, [10] and lymph node TB. [11] Immunological basis of TB-induced thrombocytopenia was supported by the presence of either platelet antigen specific antibodies or by platelet surface membrane IgG in few case reports. [12],[13] It is postulated that Mycobacterium tuberculosis could stimulate a clone of B lymphocytes directed against autologous platelets and produce antiplatelet antibodies. [12] Moreover, purified protein derivative of tuberculin may be a non-specific stimulator for B lymphocytes. [14] Boots et al.[13] described a case of immune thrombocytopenia where platelet surface membrane IgG was detected by immunoflouresence study, but there was no circulating autoantibody.

There is sufficient reason to consider thrombocytopenia in our case to be due to immune mechanism. Normal bone marrow examination excluded production defect or hemophagocytic syndrome. Absence of hepatosplenomegaly as a possible cause of platelet consumption, absence of other major illness or relevant drug therapy and rapid recovery of platelet count with IVIG therapy are other clues. However, we could not assay antiplatelet antibody or platelet-associated IgG in our patient although their absence does not invalidate the diagnosis of immune thrombocytopenia. In fact, the guideline by the American Society of Hematology (1996) considers them as 'unnecessary' tests for diagnosis of immune thrombocytopenia. [15] Temporal association of TB with purpura, recovery of platelet count after starting antituberculous drugs and IVIG, and absence of recurrence of thrombocytopenia after stopping antituberculous drugs are further evidences to suggest that thrombocytopenia was not co-existent with TB but was causally related to it.


   Conclusion Top


The actual pathophysiology, clinical importance, and therapy of TB-related immune thrombocytopenia is not fully known. But, it is important that we recognize and consider TB as a treatable secondary cause of immune thrombocytopenia, especially in areas of high endemicity of TB.

 
   References Top

1.Glasser RM, Walker RI, Herion JC. The significance of hematologic abnormalities in patients with tuberculosis. Arch Intern Med 1970;125:691-5.  Back to cited text no. 1
[PUBMED]    
2.Oyer RA, Schlossberg D. Hematologic changes in tuberculosis. In: Schlossberg D, editor. Tuberculosis & Nontuberculous Mycobacterial infections. 5 th ed. New Delhi: Tata McGraw-Hill; 2007. p. 357-64.  Back to cited text no. 2
    
3.Maartens G,Willcox PA, Benatar SR. Miliary tuberculosis: Rapid diagnosis, hematologic abnormalities, and outcome in 109 treated adults. Am J Med 1990;89:291-6.  Back to cited text no. 3
    
4.Ersley AJ. Hypersplenism and hyposlpenism In: Williams WJ, Beutler E, Ersley AJ. Lichtman MA, editors. Hematology. 4 th ed. New York: McGraw -Hill; 1990. p. 695.  Back to cited text no. 4
    
5.Rosenberg MJ, Rumans LW. Survival of a patient with pancytopenia and disseminated coagulation associated with military tuberculosis. Chest 1978;73:536-9.  Back to cited text no. 5
    
6.Toscano V, Bontadini A, Falsone G, Conte R, Fois F, Fabiani A, et al. Thrombotic thrombocytopenic purpura associated with primary tuberculosis. Infection 1995;23:58-9.  Back to cited text no. 6
    
7.Browett PJ, Varcoe AR, Fraser AG, Ellis-Pegler RB. Disseminated tuberculosis complicated by the hematophagocytic Syndrome. Aust N Z J Med 1988;18:79-80.  Back to cited text no. 7
    
8.Yasuda Y, Matsubara Y,Watanabe S, Hatakenaka R, Funastasu T, Ikeda S. A case of intractable pulmonary tuberculosis complicated by idiopathic thrombocytopenic purpura(ITP). Nihon Kyobu Geka Gakkai Zasshi 1994;42:2301-5.  Back to cited text no. 8
    
9.Talbot S, Dowling A, Dowling JP, Fuller A, Schwarz M. Mediastinal nodal tuberculosis presenting as immune thrombocytopenia. Aust N Z J Med 1998;28:465-6.  Back to cited text no. 9
    
10.Ghobrial MW, Albornoz MA. Immune thrombocytopenia: A rare presenting manifestation of tuberculosis. Am J Hematol 2001;67:139-43.  Back to cited text no. 10
    
11.Bakhshi S, Kabra M, Iyer VK, Arya LS. Thrombocytopenic purpura as a presenting manifestation of tubercular lymphadenitis. Indian J Pediatr 2003;70:993-4.  Back to cited text no. 11
    
12.Jurak SS, Aster R, Sawaf H. Immune thrombocytopenia associated with tuberculosis. Clin Pediatr 1983;22:318-9.  Back to cited text no. 12
    
13.Boots RJ, Roberts AW, McEvoy D. Immune thrombocytopenia complicating pulmonary tuberculosis: Case report and investigation of mechanisms. Thorax 1992;47:396-7.  Back to cited text no. 13
    
14.Nilsson BS, Sultzer BM, Bullock WW. Purified protein derivative of tuberculin induces immunoglobulin production in normal mouse spleen cells. J Exp Med 1973;137:127-39.  Back to cited text no. 14
    
15.George JN, Woolf SH, Raskob JE, Wasser JS, Aledort LM, Ballem PJ, et al. Idiopathic thrombocytopenic purpura: A practice guideline developed by explicit methods for the American Society of Hematology. Blood 1996;88:3-40.  Back to cited text no. 15
    

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Correspondence Address:
Sibes Kumar Das
Department of Tuberculosis and Respiratory diseases, Medical College, Kolkata
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-777X.100580

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