Disseminated tuberculosis presenting with secondary haemophagocytic lymphohistiocytosis and Poncet's disease in an immunocompetent individual

Abstract

We report a 27-year-old previously healthy man, who presented with fever and painful swelling of both ankles for 6 months, and who had been jaundiced for 1 week. Clinical examination revealed diffuse macular rash, severe pallor, deep icterus, generalised lymphadenopathy and hepatosplenomegaly. Detailed evaluation revealed granulomata in bone marrow aspirate, and numerous acid fast bacilli in lymph node biopsy. Bone marrow PCR was also positive for Mycobacterium tuberculosis. A diagnosis of disseminated tuberculosis was made and antitubercular therapy was initiated. Investigation also showed features of haemophagocytosis within the bone marrow. Results of further tests satisfied the criteria for haemophagocytic lymphohistiocytosis, probably secondary to tuberculosis. However, rapid deterioration in his clinical condition led to his death within 5 days of diagnosis, before appropriate therapy for haemophagocytic lymphohistiocytosis could be instituted. This case report highlights an unusual and deadly presentation of tuberculosis in an immunocompetent individual.

Figure 1

CT of chest and abdomen (coronal views) showing mediastinal lymphadenopathy (white arrows) and hepatosplenomegaly (black and white arrow heads).

Figure 2

Bone marrow biopsy showing granuloma formation (black arrow heads; H&E staining, magnification ×20).

Figure 3

Bone marrow aspirate showing haemophagocytosis (black arrow; H&E staining, magnification ×40).

Figure 4

Lymph node biopsy showing numerous acid fast bacilli (black arrow; Ziehl-Neelsen staining, magnification ×20).