A 19-year-old girl presented with swelling in the left side of the neck of 1 year duration. She also had fatigue and headache. She did not have any history of fever or night sweats. Physical examination revealed pallor, icterus, and multiple left cervical lymph nodes. These lymph nodes were firm, nontender, matted, and mobile. Systemic examination showed mild splenomegaly. Laboratory findings on admission were as follows: hemoglobin 3.5 g/dL, total WBC count 4800/mm3(52% neutrophils and 48% lymphocytes), platelet count 225,000/ mm3, MCV 97, MCH 30.5 fL, and reticulocyte 12%. Peripheral smear showed anisopoikilocytosis with macrocytosis and spherocytosis. Bone marrow examination showed erythroid hyperplasia. Biochemical tests were as follows: total bilirubin 3.7 mg/dL, direct bilirubin 2.0 mg/dL, indirect bilirubin 1.7 mg/dL, LDH - 720 U/L and haptoglobulin 20 mg/dL. Coomb's test done prior to transfusion was positive (Table 1 for hematological parameters before starting anti-tuberculosis therapy). Serum levels of urea, creatinine were within normal limits and glucose 6 phosphate dehydrogenase activity was normal. Serologic tests for antinuclear antibodies, human immunodeficiency virus, mycoplasma, hepatitis B and C virus were negative. Left cervical lymph node biopsy showed caseating granulomatous lymphadenitis [Figure 1] Mantoux test was positive (18 mm induration). Chest X-ray was normal and ultrasound of abdomen revealed splenomegaly.
Patient was started on antituberculosis treatment with isoniazid (300 mg qday), rifampicin (450 mg qday), ethambutol (800 mg qday), and pyrazinamide (750 mg bid). Her symptoms of fatigue and headache started improving after 2 weeks of treatment. Hemoglobin improved to 5 gm/dL after 2 weeks of treatment and Coomb's test became negative after 2 months [Table 2]. She is on follow-up and is in excellent health.