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Table of Contents
LETTER TO EDITOR
Year : 2021  |  Volume : 18  |  Issue : 1  |  Page : 64-65

Pancytopenia with autoimmune hemolytic anemia


1 Department of Pediatrics, SMS Medical College, Jaipur, India
2 Department of Medicine, SMS Medical College, Jaipur, India

Date of Submission02-Sep-2020
Date of Acceptance18-Feb-2021
Date of Web Publication22-Mar-2021

Correspondence Address:
Hemant Bagra
SMS Medical College Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_112_20

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How to cite this article:
Bargujar P, Bagra H, Pahadiya HR. Pancytopenia with autoimmune hemolytic anemia. Apollo Med 2021;18:64-5

How to cite this URL:
Bargujar P, Bagra H, Pahadiya HR. Pancytopenia with autoimmune hemolytic anemia. Apollo Med [serial online] 2021 [cited 2021 Apr 11];18:64-5. Available from: https://www.apollomedicine.org/text.asp?2021/18/1/64/311741



Sir,

A previously healthy 53-year-old man with chronic smoking presented to our hospital with a 2-month history of high-grade fever, weight loss, dry cough, and anorexia. He denied diarrhea, vomiting, hemoptysis, or hematochezia. On examination, there was no sternal tenderness and organomegaly. Lungs were clear to auscultation. Laboratory results were notable for a platelet count of 1.04 × 109/L, hemoglobin of 7.4 g/dL, white-cell count of 3.3 × 109/L, mean corpuscular volume of 78.5 fL, and normal blood sugar and serum proteins. Marked increased in erythrocyte sedimentation rate (90 at 1st hour), lactate dehydrogenase (1050 IU/L), and bilirubin (2.4 mg/dl) was noted. A peripheral blood smear was interpreted as pancytopenia having microcytic anemia with increased anisopoikilocytosis, schistocytes, and 3–4 nucleated red-cell/100 white-cell. Patient's red cells were agglutinated with anti-human globulin (IgG). Clinical and lab profiles were consistent with the diagnosis of AIHA. Blood culture was sterile and sputum was negative for acid-fast bacilli. Computed tomography of chest revealed emphysematous lung field. He tested a negative for malaria, scrub typhus, dengue, hepatitis, Epstein–Barr virus, cytomegalovirus, and human immunodeficiency virus. On further testing malignancy markers and antinuclear antibodies were found negative. A bone marrow biopsy showed slightly hypercellular marrow with normal hematopoiesis and megakaryocytes. Area of caseous necrosis and ill-defined epithelioid and Langhans giant cells was noted, confirming the diagnosis of marrow tuberculosis [Figure 1]a and [Figure 1]b. The patient did not respond to antibiotics, blood products, steroids, and antitubercular drugs, and died because of multiorgan failure.
Figure 1: (a) A bone marrow biopsy showed slightly hypercellular marrow with normal hemopoiesis and megakaryocytes. Area of caseous necrosis and ill-defined epithelioid and Langhans giant cells were noted, confirming the diagnosis of marrow tuberculosis. (b) Area of caseous necrosis and ill-defined epithelioid and Langhans giant cells were noted, confirming the diagnosis of marrow tuberculosis

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Hematological menifastations of tuberculosis are anemia, leukopenia, leukocytosis, thrombocytopenia, basophilia, monocytosis, and rarely pancytopenia. Anemia in tuberculosis is multifactorial, i.e., nutritional deficiencies, malabsorption, blood loss, drug induced, decreased iron utilization, marrow suppression, and rarely immune mediated.[1] Most of the case of AIHA in tuberculosis were found in Asian and Indian subcontinent. Pulmonary tuberculosis takes ahead in the form of tuberculosis with AIHA. Steroid with antitubercular is required in majority of disseminated tuberculosis with AIHA patient as compared to isolated tuberculosis of any site. The possible explanation for AIHA in tuberculosis could be due to dysregulated or disturbed immune system which makes antibodies against red cell surface antigens.[2]

Although the clinical presentation may be concerning for a blood disorders, careful review of the peripheral blood smear and bone marrow examination will help in diagnosis. Pyrexia of unknown origin may present with pancytopenia with AIHA due to marrow tuberculosis. Pancytopenia with AIHA in a case of marrow tuberculosis is very rare, hence we report.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bahbahani H, Al-Rashed M, Almahmeed M. Tuberculosis and autoimmune hemolytic anemia: Case report and literature review. J Appl Hematol 2014;5:164-7.  Back to cited text no. 1
  [Full text]  
2.
Rathish D, Siribaddana S. Tuberculosis induced autoimmune haemolytic anaemia: A systematic review to find out common clinical presentations, investigation findings and the treatment options. Allergy Asthma Clin Immunol 2018;14:11.  Back to cited text no. 2
    


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