An 80-year-old woman presented with a 1-month history of fever and appetite loss. Her chest computed tomography (CT) showed multiple miliary nodular shadows and some small cavitary lesions in all lung fields bilaterally (Fig. 1). Acid-fast bacteria staining of sputum was smear-positive, and tuberculosis was demonstrated in polymerase chain reaction (PCR) testing. The patient was diagnosed as having miliary tuberculosis and pulmonary tuberculosis. She was referred to our hospital and admitted to the isolation ward. She had mild mental retardation and a past history of an ovarian cyst.
On examination, her height was 152.1 cm, her weight was 42.0 kg, her temperature was 36.5  C, her blood pressure was 115/74 mmHg, her pulse rate was 91 beats/min, and her oxygen saturation was 93%. She had anemic conjunctivae and purpura of the right inguinal region and left elbow joint, but no enlarged lymph nodes.
Chest and abdominal examinations showed no specific findings. Laboratory findings showed a normal white blood cell count, anemia (Hb 7.1 g/dl), marked thrombocytopenia (Plt 3000/muL), and elevated CRP (Table 1). Coagulation, liver function, and renal function tests were normal. There was no elevation of bilirubin, urinary urobilinogen. The urine and blood cultures for acid-fast bacteria were negative. Standard anti-tuberculosis treatment (isoniazid 300 mg, rifampicin 450 mg, ethambutol 500 mg, pyrazinamide 1200 mg) was started, along with platelet transfusion after bone marrow puncture at the time of admission. There was no increase of platelets (9000/muL) despite transfusion of 10 units of platelets for two days. In her myelogram, total nucleated cell counts were normal (184,750/muL), differential counts of granulocyte and erythroblast were normal, the megakaryocyte counts were almost normal (111/muL) and no blastoid cells were found. Bone marrow findings showed normal hematopoietic capacity and some epithelioid granulomas with caseating necrosis (Fig. 2). Acid-fast bacteria staining and culture of bone marrow were both negative. Immune thrombocytopenia (ITP) was diagnosed on the basis of the lack of efficacy of platelet transfusion and normal hematopoietic capacity. Anemia improved after transfusion 2 units of RCC. Anti-Helicobacter pylori (HP) antibody, anti-nuclear antibody, and hepatitis C antibody were all negative. Platelet-associated IgG was positive (53.9 ng/107 cells). Therefore, it was considered that the thrombocytopenia was secondary ITP due to miliary tuberculosis.
There was no increase of platelets despite initiation of prednisolone 20 mg on the third day. High-dose IVIG (20,000 mg/day, 476 mg/kg) was given for 5 days because anti-tuberculosis drugs and prednisolone 20 mg were ineffective. Laboratory findings showed temporary improvement of the platelet counts (56,000/muL) on the day 11, but the platelet counts dropped to less than 10,000/muL again in several days. Eltrombopag 12.5 mg, recommended initial dose in Japan, was then added on day 17. However, no platelet increase was achieved, and the eltrombopag dose was then increased by 12.5 mg every two weeks. After prednisolone 20 mg was given for 4 weeks, the dose of prednisolone was decreased to 10 mg for three weeks. Sufficient elevation of the platelets (44,000/muL) was seen when the dose of eltrombopag reached 50 mg on day 65 (Fig. 3). The patient had no bleeding complications and no thrombotic diseases during hospitalization. During the treatment of tuberculosis, the major side effects, including liver dysfunction and rash, were not observed. The respiratory condition gradually improved in the initial two weeks. The drug sensitivity test for Mycobacterium tuberculosis showed that it was sensitive to all anti-tuberculosis drugs. The anti-tuberculosis drugs were decreased to the two drugs isoniazid and rifampicin on day 68. The sputum smear staining showed negative conversion at 5 weeks. A chest X-ray showed improvement of the miliary nodular shadows. She was discharged to her house on day 71. It was planned to give the patient standard anti-tuberculosis treatment for an extra 3 months (total 9 months) because of steroid use and the presence of miliary tuberculosis.
Chest CT on admission. . Chest CT shows multiple miliary nodular shadows and some small cavitary legions in all lung fields bilaterally. The arrows indicate some small cavitary lesions.