A 68-year-old female, a resident of Karnal (Haryana, North India), a known case of diabetes mellitus (for 5 years on diet control), and chronic liver disease (for 3 years) presented with complaints of cough, generalized weakness, and significant weight loss since one month. The cough was insidious in onset, dry in nature, and not associated with any aggravating or relieving factor. She was diagnosed with chronic liver disease 3 years ago and an evaluation was done earlier for the same and was found to be cryptogenic in origin. There were no similar complaints among her family members. On examination, she was thin built and pale. The patient was afebrile and haemodynamically stable. There were no palpable lymph nodes. Systemic examination was unremarkable.
Initial blood investigations revealed anaemia (haemoglobin 10.2 g/dl), total leucocyte count 12x109 cells/l, platelet count 150x109 cells/l, erythrocyte sedimentation rate 59 mm/hour and differential count was neutrophil 41%, lymphoctes 27% and eosinophils 32%. Mean corpuscular volume and mean corpuscular haemoglobin concentration were 84 fL and 32 g/dl, respectively. Peripheral blood smear showed normocytic normochromic anaemia with eosinophilia (figure 1). Absolute eosinophil count was 4x109 cells/l. Hepatic functions were normal except for hypoalbuminemia (2.78 g/dl). Renal function tests were normal. ELISA for HIV-1 and HIV-2, anti-hepatitis C antibody, hepatitis B surface antigen were negative. Reaction to the tubercular skin test was less than 10 mm. Chest radiograph showed increased bronchovascular markings with right hilar prominence (figure 2). Stool samples tested two times but did not reveal any ova or parasite. Ultrasound abdomen showed coarse liver echotexture. During the course of hospital stay, the patient continued to have a dry cough and generalized weakness. The patient was given deworming measures (albendazole and diethylcarbamazine). Repeat blood counts revealed persistent eosinophilia. Test for echinococcus serology was negative. Anti-filarial antibodies were negative. Tests for anti-nuclear and anti-neutrophil cytoplasmic antibodies were negative. Echocardiography was normal with no evidence of vegetation. A contrast-enhanced CT of the thorax and abdomen was done, which revealed enlarged non-necrotic mediastinal lymph nodes with features suggestive of chronic liver disease. Microscopic examination of needle-aspirated bone marrow and biopsy examination revealed increased eosinophilic precursors with no abnormal cells. Endoscopic bronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes was consistent with tubercular inflammation with acid-fast stain positive for bacilli. Acid-fast bacilli culture grew Mycobacterium tuberculosis over a period of 3 weeks in the BACTEC medium. The patient was started on anti-tubercular treatment (isoniazid, rifampicin, ethambutol, and pyrazinamide) and her eosinophil counts gradually returned to normal levels with in 1 week.