The dilemma in a case of immune thrombocytopenia in a patient with human immunodeficiency virus on antituberculosis treatment for miliary pulmonary tuberculosis

Abstract

The multifactorial mechanisms of immune thrombocytopenia (ITP) in patients with human immunodeficiency virus (HIV) and tuberculosis (TB) could be caused by HIV, TB or anti-TB drugs. No patients with HIV and opportunistic infection of miliary pulmonary TB who developed thrombocytopenia after treatment with anti-TB drugs have been reported. A 47-year-old woman with HIV/acquired immunodeficiency syndrome and miliary TB with normal platelet count (229 000/μL) started anti-TB drugs (rifampicin, isoniazid, pyrazinamide and ethambutol). After 10 days of treatment, her platelet count was low (17 000/μL). As rifampicin and isoniazid were stopped and intravenous methylprednisolone was given, her platelet count began to increase. After more than a month, her platelet count was normal (192 000/μL) and she started antiretrovirals. This improved platelet count after high-dose methylprednisolone is suggestive of ITP; however, the dilemma is whether it was rifampicin alone that caused ITP or did HIV and disseminated TB infection also play a role?

Immune-Mediated Adverse Drug Reactions (IM-ARDs) in the Form of Drug-Induced Immune Thrombocytopenia and Cutaneous Adverse Drug Reactions (CARD) Due to Clindamycin in an Human Immunodeficieny Virus (HIV) Patient

“…There has been no study on DIIT in HIV patients, although there were some reports of immune thrombocytopenia in HIV patients associated with drugs, such as amphotericin B and trimethoprim sulphamethoxazole, rifampicin, lopinavir/ritonavir, and indinavir [15][16][17]. It is unclear whether the thrombocytopenia in these HIV patients was DIIT.…”

“…The patient had taken trimethoprim sulphamethoxazole, gabapentin, folic acid, isoniazid, rifampicin, pyrazinamide, and ethambutol for 21 days, and clindamycin for 10 days. It is possible that isoniazid, rifampicin, pyrazinamide, and ethambutol caused DIIT in our patient, complicated by sepsis, which had further worsened his thrombocytopenia [ 15 – 17 ]. The qSOFA or SOFA score for sepsis was not calculated due to incomplete data, but using the Sepsis-3 criteria, he fulfilled the sepsis criteria: documented lung tuberculosis and brain toxoplasmosis plus the presence of at least one SIRS criteria including pulse 103 beats per minute and leucocyte 2950/µL on the day of admission in our hospital).…”

A case of immune thrombocytopenia due to miliary tuberculosis effectively treated with eltrombopag

“…Weber et al concluded that early diagnosis and initiation of treatment for tuberculosis should be given the highest priority to reduce the use of immunosuppressants, transfusion, and the risk of hemorrhage [ 1 ]. There are 4 new case reports of ITP due to tuberculosis after Weber's report [ [4] , [5] , [6] , [7] ]. Considering 50 cases and 4 cases, most cases obtain platelets response using anti-tuberculosis treatment, corticosteroid and IVIG.…”

“…Time from treatment initiation until platelets recovery varies from some days to a few months. No severe fetal bleeding occurred in the clinical course [ 1 , [4] , [5] , [6] , [7] ].…”