Immune cytopenia: an uncommon presentation of a common disease tuberculosis - a case series and literature review

Abstract

Various haematological abnormalities such as anaemia, leucocytosis, and pancytopenia are described in patients with tuberculosis. These often occur due to non-immunologic mechanisms. Here, we present a series of three paediatric cases with immune–mediated thrombocytopenia or haemolytic anaemia, in the setting of mycobacterial infection. This is an unusual presentation with only a few published paediatric case-reports. This is a case-series study from a tertiary hospital in North India. Medical records of three paediatric patients with immune cytopenia (IC), which was confirmed to be caused by Mycobacterium tuberculosis were reviewed. We also performed a literature search for previously reported cases of IC in children caused by tuberculosis. Three previously healthy children, between 5 to 11 years of age, presented with epistaxis, generalised petechiae, pallor and lymphadenopathy. There was no hepatosplenomegaly or bone tenderness. Laboratory investigations and bone marrow aspiration suggested megakaryocytic thrombocytopenia in all the three patients. Additionally, the first two cases had Coomb’s positive haemolytic anaemia. None of them showed a sustained clinical and haematological response to platelet transfusions and steroid therapy. Further work-up revealed histopathological, radiological and microbiological evidence of tuberculosis. The diagnosis of immune cytopenia secondary to tuberculosis was thus established. Anti-tubercular treatment (ATT) was started. All patients gradually demonstrated clinical and haematological improvement within four weeks of ATT. Follow-up at 1 year showed complete recovery in each case. Tuberculosis should be included in the etiological investigation of autoimmune cytopenia in childhood, especially in countries with high TB burden, since they respond to anti-tubercular drugs alone with a favourable outcome.