In November 2010, a 23-year-old male was referred to the Hematology Clinic of the Second Xiangya Hospital (Changsha, China) with a fever and dry cough for one week. The patient's blood routine (BR) showed a white blood cell count of 76.8x109/l, hemoglobin count of 6.6 g/dl, red blood cell count of 1.87x1012/l and platelet count of 31x109/l, with 87.80% neutrophils. Subsequently, the patient was admitted to the Department of Hematology (The Second Xiangya Hospital, Central South University, Changsha) for further evaluation. The patient had no history of tuberculosis in the family.
On admission, the patient had a body temperature of 39.0 C. No abnormality was identified on physical examination. In the peripheral blood work, lactic dehydrogenase (LDH) was high at 937.5 mu/l (upper limit of normal, 245.0 mu/l) and bone marrow aspiration revealed 77% myeloblasts. Peroxidase staining was positive and immunophenotype examination revealed that these cells had originated from myeloblastic cell lines. In addition, AML1/ETO fusion gene expression was positive. X-ray chest radiograph showed enlargement of the left hilar, laminar shadow and marginal infiltration in the right lower lung lobe. Therefore, the diagnosis of AML-M2a was determined and the induction chemotherapy was initiated, with empiric antibiotics.
However, although the BR and bone marrow aspiration indicated that the patient had achieved remission 14 days following the first cycle of chemotherapy, the patient continued to complain of repeated irregular fever and occasional frothy sputum, which did not respond to the broad-spectrum antibiotic and antimycotic treatments. During that time, sputum acid-fast smear was negative three times, and blood and sputum cultures for bacteria and fungi were sterile five times.
One month following the completion of the induction chemotherapy, the patient was administered the second cycle of chemotherapy. In order to identify the origin of the fever, bone marrow aspiration was performed again, which presented the morphology of myeloblasts to be roughly normal, accounting for 3%, with occasional hemophagocytosis. Computed tomography (CT) of the brain, abdomen and pelvis showed splenomegaly; chest CT identified multiple enlarged lymph nodes in the bilateral supraclavicular fossa, mediastinum and left hilus and a number of lymph nodes that had become confluent masses, with a maximum size of 3x4 cm (Fig. 1). In addition, the blood C-reactive protein levels were 81.70 mg/l (upper limit of normal, 8.00 mg/l), ferritin levels were 2,098.27 ng/ml (upper limit of normal, 274.66 ng/ml), LDH levels were 382.5 mu/l and fibrinogen levels were 522 mg/dl (upper limit of normal, 400 mg/dl). The immunological examination for infections of bacteria, viruses and parasites suggested PPD-antibody (Ab) IgG (+), MycoDot  (+), Widal reaction (-) and galactomannan (GM) test (-), and cardiac color ultrasound revealed marginal pericardial effusion. The patient exhibited 8 mm of induration in response to the PPD skin test. The patient was administered a diagnostic treatment, including isoniazid, rifampicin, pyrazinamide and fluoroquinolones. One week later, due to poor liver function, the rifampicin was terminated and the patient was discharged with prescriptions for isoniazid and pyrazinamide only, in January, 2011.
One month later, the patient was referred to our department again for the second consolidation chemotherapy with no complaints of fever and cough. However, several peanut-sized lymph nodes were palpated in the right supraclavicular fossa and subclavicular area, without tenderness. CT revealed enlarged lymph nodes in the bilateral supraclavicular fossa, mediastinum and left hilus. Some of the nodes had merged into masses, the maximum diameter of which was 3 cm. The air tube and bronchus were marginally compressed and bilateral pleural thickening was observed. The patient then underwent surgical excision of the supraclavicular fossa lymph node. The histology of the specimen showed caseous necrosis, epithelioid cell nodules and multinuclear giant cells (Fig. 2A). However, the acid fast bacilli (AFB) staining of this specimen was negative. Due to the liver dysfunction (high levels of transaminase and total bilirubin), only two antituberculosis drugs (isoniazid and ethambutol) and the second consolidation chemotherapy were administered simultaneously. The surgical incision healed well and the patient was discharged with prescriptions for these two antituberculosis drugs and liver protective drugs.
During the ensuing two months, the patient frequently had a cough with no fever and the biopsy incision became infected, covered by a yellow-green pyogenic moss. BR, bone marrow aspiration and AML1-ETO fusion gene showed that the patient had achieved complete remission. In addition, chest CT revealed a few massive dot shadows in the left upper lobe, with obscured edges and evidently enlarged lymph nodes of the mediastinum and left hilus, with the neighboring bronchus compressed and narrowed. Due to the fact that the tuberculosis had been poorly controlled and lung deterioration was radiographically observed, chemotherapy was interrupted. The patient received three antituberculosis drugs (isoniazid, rifapentin and ethambutol). Two months following the initiation of the three antituberculosis drug treatments, the patient continued to occasionally present with a mild fever during the afternoon; however, the patient's temperature returned to normal levels without special treatment. In addition, the dry cough continued and a yellow-green purulent ulcer continued to exist in the biopsy incision, the size of which was 1.0x0.5 cm. The patient exhibited 22 mm of induration in response to the PPD skin test and GM test (-), PPD-IgG Ab (+) and MycoDot  (+). Chest CT showed a nodular shadow in the dorsal segment of right lower lung, with rough edges, thickening bilateral bronchovascular bundles and multiple enlarged lymph nodes in the mediastinum. CT-guided percutaneous needle lung biopsy (PNLB) and fiberoptic bronchoscopy (FB) were performed. PNLB was performed several times, but all attempts failed to reach the nodule, as shown by CT. The results of FB revealed that red granulomatous materials existed at the opening of the left main bronchus, where the submucosa was swollen and congested. In addition, the opening of the left lingular bronchus exhibited red granulomatous elements, without obstruction of the lumen. However, red granulomatous materials and white necrotic elements obstructed the opening when the biopsy was performed. These observations were consistent with the diagnosis of bronchial tuberculosis (lesions of the left main bronchus, left lingular lobe and left lower lobe) and scrofula (ruptured lumens). The pathology of the specimen showed abundant coagulative necrosis, epithelioid nodules and a few Langhans giant cells (Fig. 2B). The AFB staining of the biopsy specimen and lavage fluid were negative. However, considering the patient's poor liver function and adverse reaction of liver damage by rifapentine, isoniazide and ethambutol, plus strong liver protective drugs were administered. Simultaneously, the fifth cycle of chemotherapy was initiated. During hospitalization, the patient's cough improved. To date, the patient's condition has remained stable and the AML is in remission. The patient was monitored for one year, without tuberculosis and leukemia relapse. The patient provided written informed consent.