A 67-year-old man was treated with cladribine for hairy cell leukaemia. A few weeks later, he presented with persistent headaches, intermittent hypoesthesia of the right upper limb and language impairment. Brain CT scan showed 3 contrast-enhancing lesions. MRI revealed infracentimetric nodular lesions with restricted diffusion. One of the lesions was surgically removed and tested positive for acid-fast bacilli. Moreover, Mycobacterium tuberculosis was confirmed by PCR. Antituberculous drugs were prescribed for 12 months, with complete resolution of neurological deficits. This case highlights the risk of mycobacterial infections associated with both hairy cell leukaemia and cladribine use, and the importance of screening and treatment of latent forms of tuberculosis in patients undergoing treatment with immunosuppressive drugs.

Marchiafava-Bignami disease (MBD) is a disorder associated with chronic alcohol consumption and characterized by demyelination and necrosis of the corpus callosum. Patients may have reduced consciousness, psychotic symptoms, apathy, hemiparesis, ataxia and coma. Although some cases of recovery have been reported, the outcome is poor, with disability or dead. We reported a case of a 56-year-old woman with chronic alcoholism admitted to our hospital with impaired consciousness and a history of gait disturbance. On examination, she was in a coma, with increased muscle tone and left arm paresis. Laboratory studies showed a folic acid deficiency and the CT scan was normal. Magnetic resonance imaging revealed lesions in periventricular white matter and the entire corpus callosum with restriction of water diffusion consistent with the diagnosis of MBD. Despite treatment with B vitamin complex, the patient died. Coma and radiological involvement of the entire corpus callosum are compatible with type A MBD and associated with poor prognosis. Although being a rare alcoholism complication, it should not be forgotten since an early diagnosis and prompt supportive therapy may enable a better outcome.

The hematological manifestations of cobalamin (vitamin B12) deficiency may range from asymptomatic to life-threatening forms. Pseudothrombotic microangiopathy is a rare but severe presentation, characterized by the presence of hemolysis and schistocytosis, that is completely reversible after vitamin supplementation.We present a challenging diagnostic approach of a 55-year-old man who presented with high hemolytic markers, pancytopenia, and schistocytes on the peripheral smear due to acquired cobalamin deficiency. Subsequent testing revealed positive anti-intrinsic factor and anti-parietal cell antibodies consistent with pernicious anemia. Cobalamin replacement led to the resolution of microangiopathic hemolysis and clinical improvement, thereby confirming the diagnosis. This case highlights the importance of early recognition of this syndrome, which is often misdiagnosed as true microangiopathic hemolytic anemia, confounding appropriate management.