Hemophagocytic lymphohistiocytosis and miliary tuberculosis in a previously healthy individual: a case report
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CASE REPORT
Hemophagocytic lymphohistiocytosis and miliary tuberculosis in a previously healthy individual: a case report Linn Hereide Trovik1, Miriam Sandnes2, Bjørn Blomberg1,2, Gunhild Holmaas3, Aymen Bushra Ahmed1, Tor Henrik Anderson Tvedt1, Olav Vintermyr4,5 and Håkon Reikvam1,2*
Abstract Background: Hemophagocytic lymphohistiocytosis (HLH) is a rare heterogenous genetic or acquired hyperinflammatory syndrome associated with a high degree of morbidity and mortality. HLH has clinical manifestations related to abnormal prolonged activation of T lymphocytes and macrophages with an excess of proinflammatory cytokines. The main causes of secondary HLH are malignancies and infectious diseases. Case presentation: The patient was a 54-year-old man, originally from Eastern Africa, who had lived in Northern Europe for 30 years. Here we describe the clinical features, laboratory parameters, diagnostic workup, management and outcome data of a previously healthy 54-year-old man diagnosed with HLH secondary to tuberculosis. The patient was initially treated for a community-acquired pneumonia. He developed multiorgan failure with acute respiratory distress syndrome, hypertransaminasemia, and kidney and bone marrow dysfunction. The clinical course together with a simultaneous increase in serum ferritin raised the suspicion of HLH. The patient fulfilled seven out of eight diagnostic criteria for HLH. A thorough diagnostic workup with respect to HLH and a potential underlying disease was initiated. Cultivation of bronchoalveolar lavage fluid, stool and urine, and polymerase chain reaction of epithelioid cell granulomas in the bone marrow were all positive for Mycobacterium tuberculosis. He was treated for both HLH and tuberculosis, and he survived without any sequelae. Conclusions: We present one of few published cases of a patient who survived HLH triggered by miliary tuberculosis. The current case illustrates the need for awareness of these two diagnoses, and the timely initiation of specific and supportive treatment to reduce mortality. Keywords: Cytokines, Ferritin, Hemophagocytic lymphohistiocytosis, Infection tuberculosis Introduction Hemophagocytic lymphohistiocytosis (HLH) is an uncommon hematologic disorder characterized by an uncontrolled immune response with organ infiltration of lymphocytes and histiocytes, and organ damage caused by excessive production of pro-inflammatory cytokines *Correspondence: [email protected] 2 Department of Clinical Science, Institute of Clinical Science, University of Bergen, Bergen, Norway Full list of author information is available at the end of the article
[1–6]. HLH is categorized either as primary due to a genetic disorder, or as secondary due to an acquired condition. Secondary HLH can be triggered by neoplastic and non-neoplastic diseases [7]. Malignancies associated with secondary HLH are mainly various hematological malignancies such as leukemia or lymphoma, whereas autoimmune disorders and infectious diseases are the most common nonmalignant diseases
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