A Rare Case of Disseminated Tuberculosis of the Bone Marrow in Systemic Lupus Erythematosus

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Abstract

Patients with systemic lupus erythematosus (SLE) are susceptible to tuberculosis (TB), especially in endemic areas such as China. The variable and nonspecific clinical features of disseminated TB often leads to an erroneous or misdiagnosis. When a patient presents with TB of the bone marrow, the clinical condition is more perplexing and the prognosis is typically poor. Till now, there is no case report after apatinib came in the market.

Here, we report a case of TB of the bone marrow accompanied with SLE. The patient exhibited remarkable features, including widespread lesions in the lungs, spinal vertebrae, sacrum, and ilium that were found to be consistent with TB of the bone marrow after histopathological examination.

This case highlights the importance of clinical suspicion for TB during the follow-up of SLE patients, especially in endemic areas. An aggressive diagnostic biopsy should be performed in suspected TB patients as early as possible.

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Most cited references 11

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Glucocorticoid use, other associated factors, and the risk of tuberculosis.

Susan S Jick, Eric S Lieberman, Mahboob U Rahman … (2006)

To evaluate the association of glucocorticoids and other purported risk factors with the development of tuberculosis. We conducted a case-control study of tuberculosis cases identified during 1990-2001 using the General Practice Research Database in the United Kingdom. Cases were patients with a first time diagnosis of tuberculosis accompanied by at least 6 months of treatment with at least 3 different tuberculosis medications. Up to 4 controls were matched to each case on age, sex, the practice attended by the case, index date, and amount of prior computerized records. The study encompassed 497 new cases of tuberculosis and 1,966 controls derived from 16,629,041 person-years at risk (n = 2,757,084 persons). The adjusted odds ratio (OR) of tuberculosis for current use of a glucocorticoid compared with no use was 4.9 (95% confidence interval [95% CI] 2.9-8.3). The adjusted ORs for use of or =15 mg of prednisone or its equivalent daily dose were 2.8 (95% CI 1.0-7.9) and 7.7 (95% CI 2.8-21.4), respectively. Adjusted ORs of tuberculosis were 2.8 for patients with a body mass index (BMI) <20 compared with normal BMI; 1.6 for current smokers compared with nonsmokers; and 3.8, 3.2, 2.0, and 1.4 for those with history of diabetes, emphysema, bronchitis, and asthma, respectively, compared with those without such history (all P values <0.05). These results indicate that patients treated with glucocorticoids have an increased risk of developing tuberculosis, independent of other risk factors. Low adiposity, diabetes, current smoking, and obstructive pulmonary disorders are also important independent risk factors for tuberculosis.

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Cytotoxic T lymphocyte-mediated killing using granzyme B has recently been proposed to be a preferential and selective source of autoantigens in systemic autoimmune diseases, including systemic lupus erythematosus (SLE), while other reports have indicated that cytolytic activity in SLE patients was decreased. The aim of this study was to examine the phenotypic and functional status of the CD8+ T cells in SLE patients. Phenotype analysis of CD8+ T cells was carried out using flow cytometry. The cytotoxic potential of CD8+ T cells and its consequences were examined in redirected-killing experiments. SLE patients with quiescent disease (n = 41) were compared with SLE patients with active disease (n = 20), normal individuals (n = 36), and control patients with vasculitis (n = 14). Cytotoxic CD8+ T cell differentiation was examined by coculture with differentiated dendritic cells (DCs) in the presence of SLE patient sera. Patients with disease flares were characterized by higher proportions of perforin- and/or granzyme B-positive lymphocytes with a differentiated effector phenotype (CCR7- and CD45RA+). The frequency of these cells in peripheral blood correlated with clinical disease activity as assessed by the SLE Disease Activity Index. These cells generated high amounts of soluble nucleosomes as well as granzyme B-dependent unique autoantigen fragments. Finally, the activation of DCs with serum from a patient with active lupus induced granzyme B expression in CD8+ T lymphocytes. DCs generated in the presence of sera from SLE patients with active disease could promote the differentiation of CD8+ effector T lymphocytes that are fully functional and able to generate SLE autoantigens. Our data disclose a new and pivotal role of activated CD8+ T lymphocytes in SLE pathogenesis.

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Kwen-Tay Luh, I-Shiow Jan, Na Lee … (2006)

Disseminated tuberculosis remains a diagnostic challenge because the presentations are nonspecific. In the current retrospective study we describe the clinical characteristics and outcome of disseminated tuberculosis. From January 1995 to December 2004, patients with culture-confirmed tuberculosis who fulfilled the criteria for disseminated tuberculosis were selected and their medical records reviewed. Their clinical isolates were genotyped. Of the 3058 patients with culture-confirmed tuberculosis, 164 (5.4%) had disseminated disease; 14.0% of patients had acquired immunodeficiency syndrome. The most common radiographic finding was miliary lung lesions (47.0%); 31.1% of patients died at the end of the study. Poor prognostic factors included hypoalbuminemia, hyperbilirubinemia, renal insufficiency, and delayed antituberculosis treatment. Clinical findings suggestive of disseminated tuberculosis were miliary lung lesions, serum ferritin >1000 microg/L, infiltrative liver disease, and adjusted calcium >2.6 mmol/L. Simultaneously performing mycobacterial culture and histopathologic examination of bone marrow biopsy was more sensitive and faster than just performing mycobacterial blood culture in diagnosing disseminated tuberculosis. Of the 64 preserved Mycobacterium tuberculosis isolates, 47 (73.4%) were clustered and 27 (42.2%) were Beijing family. Since prognosis was worse in patients with delayed treatment, a high index of suspicion is required, especially in those with clinical findings suggestive of disseminated tuberculosis.

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Author and article information

Journal

Journal ID (nlm-ta): Medicine (Baltimore)

Journal ID (iso-abbrev): Medicine (Baltimore)

Journal ID (publisher-id): MEDI

Title: Medicine

Publisher: Wolters Kluwer Health

ISSN (Print): 0025-7974

ISSN (Electronic): 1536-5964

Publication date Collection: May 2016

Publication date (Electronic): 06 May 2016

Volume: 95

Issue: 18

Electronic Location Identifier: e3552

Affiliations

From the Department of Rheumatology (DC, YY, ZZ, Xiuyan Yang), the First Affiliated Hospital of Sun Yat-sen University, Guangzhou,China; and Department of Pathology (ZY), the First Affiliated Hospital of Sun Yat-sen University, Guangzhou,China.

Author notes

Correspondence: Zhongping Zhan, Department of Rheumatology, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (e-mail: zhanchuyue@ 123456163.com ).

Article

Accession ID: 03552

DOI: 10.1097/MD.0000000000003552

PMC ID: 4863787

PubMed ID: 27149470

SO-VID: 41d73f6b-f965-4264-b2f9-ca72f13e2a34

License:

This is an open access article distributed under the Creative Commons Attribution License 4.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0

History

Date received : 5 February 2016

Date revision received : 29 March 2016

Date accepted : 29 March 2016

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A Rare Case of Disseminated Tuberculosis of the Bone Marrow in Systemic Lupus Erythematosus : Case Report

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