A 26 year old Indian male with no prior comorbidities and not on any recent medication presented with bilateral progressive non tender neck swelling for 40 days, weight loss of about 10 kgs in 2 months, bilateral multiple small and large joint pains of both legs and tingling and numbness of left 1st and 2nd toes for 26 days, petechial rash over lower limbs and trunk for 1 day. He had epistaxis for 1 hour for which he was rushed to emergency room.
On examination, the patient is pale, no icterus, and found to have bilateral enlarged, mobile, nontender cervical lymph nodes : no axillary and inguinal lymphadenopathy. Petechial rashes were found over lower limbs and trunk. He is afebrile with normal vitals. Active bleeding observed from the right nostril. His blood count revealed Hb - 9.70 gm%, TLC- 9100 cells/cumm, platelets - 3000 cells/cumm, ESR- 12mm/hr. Liver function tests, coagulation profile, blood urea, serum creatinine, CUE, serum electrolytes were within normal range. Peripheral smear showed microcytic hypochromic RBC, Neutrophilic predominance, platelets on smear were reduced and no abnormal cells were found. HIV, HCV, HBsAg, VDRL were Non-reactive. ANA was negative. His Chest X-ray and ultrasound abdomen were normal. B12, folic acid, procalcitonin levels were normal. Coombs test is negative. Serum LDH is 710 U/L.
In the further workup, USG guided FNAC of the right cervical lymph node is suggestive of granulomatous lymphadenitis with caseous necrosis. AFB Smear and Genexpert were positive and rifampicin sensitive (Fig. 1, Fig. 2).
Bone marrow study suggestive of peripheral bicytopenia with cellular marrow, normoblastic erythropoiesis, and megakaryocytic thrombocytopenia. (Fig. 3). MRI of lumbosacral spine was showing (Fig. 4) altered signal intensities in multiple vertebral bodies in whole spine suggestive of TB osteomyelitis. Small abscess in paraspinal muscles at the level of D12 - L1 on the left side. Pus aspirated from the abscess showed AFB and Genexpert positive and rifampicin sensitive, Suggestive of Pott's spine.
In view of severe thrombocytopenia and active uncontrolled epistaxis considered platelets products transfusion. After transfusion of one SDP platelet count increased from 3000 to 5000 per microliter and patient, continue to have epistaxis. So we Considered IVIg 1 gm/kg body weight as a single dose and corticosteroids dexamethasone along with second SDP transfusion. Dexamethasone 40mg IV for four days given followed by tapering the dose of prednisolone. Epistaxis controlled with all the above measures and nasal pack. The patient was started on category -1 ATT according to RNTCP guidelines.
Platelets count increased to 80,000 per microliter after one week and reached to above 1,50,000 per microliter after two weeks of the ATT and prednisone therapy. There was no fresh bleeding from any sites, and no new petechiae and purpura. Prednisone was then tapered off over a period of one month. The patient was followed-up for ten months in the outpatient department, and there was no recurrence of thrombocytopenia. Follow up MRI spine after 9 months was showing completely resolved paraspinal abscess. After exclusion of all other secondary causes of thrombocytopenia and failure of first-line ITP treatment and prompt response to Anti-tuberculosis treatment it is highly suggestive of TB is the causality of ITP.