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LETTER TO EDITOR
Year : 2013  |  Volume : 50  |  Issue : 4  |  Page : 321
 

Disseminated tuberculosis mimicking relapse in hairy cell leukemia


1 Department of Medical Oncology, Dr. B. R. A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
2 Lab Oncology, Dr. B. R. A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication24-Dec-2013

Correspondence Address:
V Raina
Department of Medical Oncology, Dr. B. R. A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.123608

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How to cite this article:
Gogia A, Raina V, Gupta R. Disseminated tuberculosis mimicking relapse in hairy cell leukemia. Indian J Cancer 2013;50:321

How to cite this URL:
Gogia A, Raina V, Gupta R. Disseminated tuberculosis mimicking relapse in hairy cell leukemia. Indian J Cancer [serial online] 2013 [cited 2019 Aug 24];50:321. Available from: http://www.indianjcancer.com/text.asp?2013/50/4/321/123608


Sir,

Unusual presentations of hairy cell leukemia (HCL) include, marked leucocytosis, spontaneous splenicrupture, bulky lymphadenopathy, bone lesions, neuropathy, meningitis and ascites. [1],[2] We report 52-years-old male presented with pancytopenia and ascites.

A 52-years-old male presented with 6 months history of fever, fatigue, weight loss, pancytopenia, splenomegaly and ascites. On evaluation he had 40% hairy cell in bone marrow aspirate, which were positive for CD19, CD20, CD11c, CD25 and CD103 and kappa light chain restriction consistent with HCL. Hairy cells was also found in ascetic fluid and serum/ascetic fluid albumin radient ratio of <1.1. Rest of staging workup including contrast enhancement computer tomogram (CECT) of chest and abdomen was normal except 13 cm spleen and ascitis. There was no history of tuberculosis in past. The patient was treated with cladribine 0.14 mg/kg/day as 2 h infusion for 5 days. He achieved complete remission after cladribine and kept under follow-up. After 6 months, he again presented with pancytopenia, splenomegaly (12 cm) and reappearance of ascites. Clinical features were suggestive of relapse of disease. Investigation revealed hemoglobin 9.3 g/dL, white blood cell count 2.1 × 10 9 /L, and platelets 64 × 10 9 /L. Bonemarrowexaminationwasnormal. Bone marrow biopsy revealed 45-50% cellularity with hematopoitic elements of all series was identified. Serology for HIV was negative. CECT scan chest showed mild pleura-pericardial effusion and CECT abdomen revealed multiple small hypodense lesions in both the lobes of liver, splenomegaly with multiple deposits [Figure 1]. Mantoux test was negative. Abdominal paracentas is showed straw colored fluid with serum/ascetic fluid albumin radient ratio of <1.1, cell count 460/mm 3 P40 L60, Gram staining negative, acid fast bacillus negative, adenosinedaminase (ADA) level 90U/L, polymerase chain reaction (PCR) for tuberculosis was positive. The final diagnosis of disseminated tuberculosis was made was made and he was put on ant tubercular treatment (ATT) containing rifampicin, isoniazide, pyrazinamide and ethombutol. Clinical sign (normal size of spleen on ultrasonogram and no evidence of ascitis), symptoms and hematological parameters improved after 2 months of ATT. He completed 9 months of ATT and remains off treatment for 6 months without any illness.
Figure 1: CECT scan chest: Plero-pericardial effusion (a), CECT scan abdomen: Multiple small hypodense lesions in both the lobes of liver, splenomegaly with multiple deposits (b)

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Disseminated tuberculosis in one of the complications of chronic lymphoproliferative disorders. It occurs by either reactivation of acid fast bacilli by due to disease chemotherapy (fludarabine and cladribine) induced immune suppresion, in Indian patients where the prevalence of subclinical tuberculosis is high. Diagnostic criteria of disseminated tuberculosis are as follows: (a) Clinical feature compatible with tuberculosis, (b) concurrent involvement of atleast two non-adjacent organs or sites of the body, or detection of mycobacterium tuberculosis in the blood or bone marrow, (c) microbiologic and/or histologic evidences of tuberculosis, (d) significant improvement with anti-tubercular treatment. [3],[4] Disseminated tuberculosis may mimic the features of pancyopenia and hypersplenism. [3],[4],[5] In our case ascetic fluid PCR, ADA level were raised, sign and symptoms was completely improved with antitubercular treatment.

This report highlight reappearance of baseline features not always relapse of disease, the risk of immune suppression due to chemotherapy particular cladribine in Indian patients where the prevalence of tuberculosis is high.

 
  References Top

1.Bouroncle BA. Unusual presentations and complications of hairy cell leukemia. Leukemia 1987;1:288-93.  Back to cited text no. 1
[PUBMED]    
2.Kayal S, Radhakrishnan V, Singh S, Chopra A, Kumar R, Raina V. Hairy cell leukemia with ascites: An unusual presentation. Leuk Lymphoma 2011;52:539-40.  Back to cited text no. 2
[PUBMED]    
3.Heravi MM, Khanbanpoor M. Disseminated tuberculosis presenting as hypersplenism Iran. J Clin Infect Dis 2008;3:39-42.  Back to cited text no. 3
    
4.Chen CH, Fang YH, Chiang PM, Lin DT, Huang LM. Disseminated tuberculosis presenting as multiple hepatosplenic microabscesses and pancytopenia in a teenage boy. J Formos Med Assoc 2004;103:939-42.  Back to cited text no. 4
[PUBMED]    
5.Cassim KM, Gathiram V, Jogessar VB. Pancytopaenia associated with disseminated tuberculosis, reactive histiocytic haemophagocytic syndrome and tuberculoushypersplenism. Tuber Lung Dis 1993;74:208-10.  Back to cited text no. 5
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