Miliary Tuberculosis With Tubercular Meningitis With Thrombocytopenic Purpura

摘要

Disseminated Tuberculosis presenting with thrombocytopenia is a rare condition, especially in children. We describe a case of miliary tuberculosis with tubercular meningitis and thrombocytopenic purpura. An early suspicion to the diagnosis was made by clinical, radiological, pathological evidences and confirmed by the response to therapy. The patient was successfully treated with antituberculous chemotherapy and steroids. Introduction Hematologic abnormalities have been described in association with mycobacterial infections for almost 100 years. A comprehensive review of the literature reveals around 16 case reports documenting tuberculosis as a cause of severe hematologic conditions 1 .Tuberculosis should be considered a cause of immune thrombocytopenia in areas where tuberculosis is highly endemic. Here we report a spectrum of tuberculosis manifestations namely tubercular meningitis and miliary tuberculosis with thrombocytopenic purpura in a 13 year old child who was successfully treated with antituberculous chemotherapy. Case Report A thirteen year old previously healthy female was admitted to our hospital with chief complaints of fever, loss of appetite since the last 25 days. She had severe headache and vomiting since the last six days, prior to presentation. Her parents had noticed some reddish spots on her arms and legs since one week. They denied any history of hematologic disorders or blood transfusions, and she was not receiving any drugs. The family history was nonc ontributory. Clinical examination revealed a febrile child(101 0 F) with pallor and icterus. Vitals BP-88/60mmHg,PR-130/min,RR-36/minute. Respiratory examination was normal except for fine crepitations present in the bilateral lung bases. Neck rigidity was present with a positive Kernig's sign and plantar response was withdrawal bilaterally. Abdomen was soft with mild hepatomegaly but no splenomegaly. Petechial rash was present on both the lower limbs and hands. A skiagram of the chest showed multiple micronodular lesions suggestive of military picture(Fig-1). Mantoux test with 5TU gave 22mm induration. Routine blood investigations Hb- 7.9g%,TLC-4000/mm 3 ,DLC-P62L34E2M2%,platelet count 18000/mm 3 and a Normocytic normochromic blood picture with anisocytosis . LFT bilirubin total 2.0mg% with direct 1.2mg%,SGPT -84U/L,SALP-553U/L. Renal functions were within normal limits. ELISA for HIV was nonreactive. Bone marrow examination showed a normocellular bone marrow with a myeloid erythroid ratio(1.5:1). Megakaryocytes were seen in adequate numbers with almost absent platelet synthesis. No abnormaleoplastic cell was seen. No granuloma was seen in the bone marrow. The child was not able to raise sputum and because of the poor socioeconomic status in the family, we did not do an antibody test for evaluating the cause for thrombocytopenia.CSF study showed a lymphocyte predominant fluid with TLC of 160 cells.The sugar, protein of the CSF sample was 35mg% and 80mg% respectively. No AFB was demonstrable and gram stain was not showing any organism. Taking into consideration her poor general condition, TB meningitis and the blood dyscrasia, she was started on steroids and we gave her 4 packed cell transfusions and 4 platelet concentrates.Deranged liver functions limited the full range of ATT and we had to start with streptomycin injection and ethambutol only. With normalisation of her LFT we added drugs in a stepwise manner within one week to put up a regimen of S 0.5 R300 H300 Z750.. In two weeks her Hb rose to 8.2g% and her platelet count reached 70000/mm 3 . The platelet count recovered to normal one month after therapy and her anaemia also improved with ATT. Oral steroids were withdrawn following this and ATT continued. The initial regimen of SHRZ for two months was followed by R300H300Z750 with a total duration of therapy of 9 months. There was no evidence of any recurrence in thrombocytopenia or hemolysis following this. The patient recovered fabulously with a