Ruxolitinib
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Tracheobronchial tuberculosis and disseminated tuberculosis: 2 case reports In a case series, two men aged 41–66 years were described, of which one patient developed tracheobronchial tuberculosis and another patient developed disseminated tuberculosis during treatment with ruxolitinib for primary myelofibrosis (PMF). Case 1: A 41-year-old man presented to hospital for fatigue, satiety and abdominal distension in March 2018. Clinical evaluation revealed that the spleen’s lower edge reached the umbilicus level, increased age-adjusted cellularity with granulocyte proliferation, decreased erythropoiesis, a large number of megakaryocytes atypia, grade 0 fibrosis and the JAK2V617F mutation. He was eventually diagnosed with pre-primary myelofibrosis (PMF). The Dynamic International Prognostic Scoring System (DIPSS) risk group was intermediate-1. Hence, he started receiving ruxolitinib [rux; route not stated] 20mg twice daily. In early July, he started experiencing fever and productive cough, which lasted approximately one week. On 12 July, he was hospitalised for antibiotic treatment. Laboratory tests revealed the following: WBC 16.11 × 109/L, erythrocyte sedimentation rate (ESR) 40 mm/h, hypersensitive C-reactive protein 107.7 mg/L, procalcitonin (PCT) 0.76 µg/L, absolute total T cell count 347 /µL and CD4+ T cell count of 208 /µL. The sputum acid-fast bacilli (AFB) smears were negative, but the interferon gamma release assay (IGRA, TSPOT.TB) was positive. The next morning, transient syncope unexpectedly occurred. Ultrasound confirmed multiple deep venous thrombosis in his left lower extremity. A CT scan revealed pulmonary thromboembolism in his right upper and inferior pulmonary artery, pulmonary infection, bilateral pleural effusion, multiple enlarged mediastinal lymph nodes and soft tissue shadows that surrounded his left main bronchus. It also revealed frontal lobe haemorrhage. Subsequently, ruxolitinib was discontinued, and he received low molecular weight heparin instantly. Then, he was transferred to vascular surgery for inferior vena cava filter implantation. Iodine contrast oesophagogram was performed in response to dry cough, which showed a broncho-oesophageal fistula on his left main bronchus. He then received nasal jejunal nutrition. In September, hydroxyurea was introduced to control the WBC count. Bronchoalveolar lavage fluid (BALF) specimens tested negative for culture, GeneXpert assay and AFB. A tracheobronchial lymph node biopsy confirmed Mycobacterium tuberculosis (MTB) by PCR. Thus, he was diagnosed with tracheobronchial tuberculosis (TBTB), and he received a 12-month antituberculosis therapy (ATT) involving isoniazid, rifampicin, ethambutol and levofloxacin. During ATT, BALF was negative, including mycobacterial RNA and DNA. Also, the size of mediastinal lymph nodes decreased. In July 2019, ruxolitinib was restarted due to splenomegaly and abdominal distension. At this time, the DIPSS was intermediate-1. Case 2: A 66-year-old man was diagnosed with PMF in December 2010. Further evaluation reveale
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