A 29-year-old previously healthy immigrant male patient from Kazakhstan was admitted to hospital with new-onset severe hemoptysis, macroscopic hematuria and extensive cutaneous petechiae on lower extremities. He appeared ill and poorly nourished. The patient was oriented and well cooperated, and there was no previous history of hematologic or liver or another disease and recent medication. He presented with unexplained weight loss of 2 months duration along with intermittent fever, night sweats and cough. The physical examination revealed a blood pressure of 100/70 mm/Hg, pulse 100/min, a temperature 37.2 C, extensive cutaneous petechiae on lower extremities, hemorrhagic bulla on tongue and on mucosa of oral cavity, and amphoric souffle on apex of right chest. No organomegaly or lymphadenomegaly or evidence of another disease such as chronic liver disease was detectable. The initial complete blood count revealed a white blood cell 25.1 x 109/l (58% neutrophils, 29% bants, 9% lymphocytes and 4% monocytes), hemoglobin 11.2 gr/dl, hematocrit 36%, MCV 84 fl, reticulocytes 1% and platelet count 7.6 x 109/l. Erythrocyte sedimentation rate was 110 mm/h. A peripheral smear was remarkable for a paucity of platelets. Coagulation profile [prothrombin time (PT), activated-partial thromboplastin time (aPTT), fibrin degradation products (FDP)] were normal. A bone marrow aspiration demonstrated hypercellularity of all cell lines with normal maturation of myeloid and erythroid precursors. Megakaryocytes were increased in number with normal morphology. On bone marrow aspiration hemophagocytosis was not observed. A chest X-ray (Figure 1) and computed tomography (CT) (Figure 2) demonstrated bilateral patchy infiltrates and walled cavities on left and right upper lobes. Acid-fast bacilli were strongly positive in sputum (Figure 3). Bone marrow aspirate and urine for acid-fast bacilli were negative. Sputum culture yielded mycobacterium tuberculosis complex. The following laboratory studies were normal or negative: biochemical tests (glucose, urea, creatinine, uric acid, sodium, potassium, calcium, chloride, phosphorus, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, lactate dehydrogenase, bilirubin, total protein and albumin), rheumatoid factor, anti-nuclear antibody, anti-platelet specific antibodies, Coomb's tests, HIV, hepatitis B and C virus, blood culture, bone marrow aspirate culture and abdominopelvic CT. No granuloma or hemophagocytosis was detected on bone marrow biopsy. The patient was started on rifampin 10 mg/kg/d, isoniazid 5 mg/kg/d, ethambutol 25 mg/kg/d, pyrazinamide 40 mg/kg/d, pyridoxine 75 mg/d and intravenous immune globulin (IVIg) 1 g/kg/d given for 2 days. On day 2 of hospitalization and treatment of anti-tuberculous therapy prednisolone 1 mg/kg/d was added. On day 8, platelet counts started to increase and on day 12 of the treatment it reached to 187 x 109/l level. Patient improved on day 10 and he did not have any complaints on day 14; at time of discharge. He received a total of 6 red blood cell (RBC) units throughout hospitalization. During his hospitalization findings of hemolysis or gastrointestinal bleeding and massive bleeding in another site except hematuria and hemoptysis were not established. A complete blood count at discharge demonstrated a WBC 17 x 109/l, Hb 9.6 g/dl, and platelet count 310 x 109/l (Table 1). Corticosteroids were discontinued on day 14 of therapy and the patient was discharged and recurrent thrombocytopenia was not established after withdrawal of corticosteroid therapy. Ninety days after discharge, the patient was well with a platelet count of 300 x 109/l (Table 1) and he had no side effect thought to be secondary to anti-tuberculous drugs.
CT showing cavitary lesions in both lungs.