Tuberculosis and immune hemolytic anemia
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《美国医学杂志》
Department of Pediatrics, AIIMS, New Delhi, India
We read with great interest the clinical brief by Gupta et al[1] (February 2005) on "Abdominal tuberculosis with autoimmune hemolytic anemia". We do not agree with the statement that this is the first case report of tuberculosis with autoimmune hemolytic anemia.
Anemia is present in 63% of miliary tuberculosis patients.[2] There are several reports associating mycobacterial disease with anemia, and several mechanisms have been proposed: nutritional deficiency, failure of iron utilization, malabsorption syndrome and marrow suppression.[2] The association of autoimmune hemolytic anemia with tuberculosis, although extremely rare, is known for quite long. An early experimental study[3] in Germany showed that the injection of tubercle bacilli or their products produce hemolytic anemia, pancytopenia and myelofibrosis in small animals. To our knowledge, since then, 7 cases of autoimmune hemolytic anemia in association with tuberculosis have been reported in medical history. One case has been reported recently from the AIIMS in one of the issues of the Indian Journal of Pediatrics by Bakhshi et al[4] on autoimmune hemolytic anemia in association with childhood tuberculosis. In humans, disseminated tuberculosis may occasionally provoke a marked proliferation of reticuloendothelial tissues, resulting in varied and severe hematological disorders through immune mechanisms.[5] Regarding therapy, there are reports in adult literature that hemolysis associated with tuberculosis has responded to antitubercular therapy alone.[6], [7], [8] Steroids are useful in addition to antitubercular therapy if there is severe hemolysis. On the other hand, there is a report of autoimmune hemolytic anemia in association with miliary tuberculosis that required splenectomy.[9]
In view of the known autoimmune associations of tuberculosis such as vasculitis, arteritis and immune thrombocytopenia, and based on the available reports of autoimmune hemolytic anemia in tuberculosis, it is reasonable to suspect and rule out tuberculosis as a possible association in patients with autoimmune hemolytic anemia in children in areas of high endemicity of tuberculosis. This is especially important, as autoimmune hemolytic anemia may require long-term steroid therapy that can aggravate tuberculosis. Physicians should rapidly start antituberculosis therapy once the diagnosis is being made. Caution should also be exercised when selecting rifamycin or para amino salicylic acid for these patients, since both drugs are known to induce hemolytic anemia.[4]
References
1. Gupta V, Bhatia BD. Abdominal tuberculosis with autoimmune hemolytic anemia. Indian J Pediatrics 2005; 72(2) : 175-176.
2. Glasser RM, Walker RI, Hewrion JC. The significance of hematologic abnormalities in patients with tuberculosis. Arch Intern Med 1970; 125: 691-695.
3. Berkowitz FE, Hemolysis and infection: categories and mechanisms of their interrelationship. Rev Infect Dis 1991; 13:1151-1162.
4. Bakhshi S, Rao IS, Jain V, Arya LS. Autoimmune hemolytic anemia complicating disseminated childhood tuberculosis. Indian Journal of Pediatrics 2004; 71 : 549-551.
5. Cameron SJ. Tuberculosis and the blood: a special relationship Tubercle 1974; 55 : 55-57.
6. Murray HW. Transient autoimmune hemolytic anemia and pulmonary tuberculosis. N Engl J Med 1978; 299: 488.
7. Siribaddana S, Wijesundara A. Autoimmune hemolytic anemia responding to antituberculous treatment. Tropical Doctor 1997; 27: 243-244.
8. Kuo PH, Yang PC, Kuo SS, Luh KT. Severe immune hemolytic anemia in disseminated tuberculosis with response to antituberculosis therapy. Chest 2001; 119: 1961-1963.
9. Blanche P, Rigolet A, Massault D, Bouscary D, Dreyfus F, Sicard D. Autoimmune hemolytic anemia revealing miliary tuberculosis. J Infect 2000; 40: 292.(Sahu Jitendra K, Kabra SK)
We read with great interest the clinical brief by Gupta et al[1] (February 2005) on "Abdominal tuberculosis with autoimmune hemolytic anemia". We do not agree with the statement that this is the first case report of tuberculosis with autoimmune hemolytic anemia.
Anemia is present in 63% of miliary tuberculosis patients.[2] There are several reports associating mycobacterial disease with anemia, and several mechanisms have been proposed: nutritional deficiency, failure of iron utilization, malabsorption syndrome and marrow suppression.[2] The association of autoimmune hemolytic anemia with tuberculosis, although extremely rare, is known for quite long. An early experimental study[3] in Germany showed that the injection of tubercle bacilli or their products produce hemolytic anemia, pancytopenia and myelofibrosis in small animals. To our knowledge, since then, 7 cases of autoimmune hemolytic anemia in association with tuberculosis have been reported in medical history. One case has been reported recently from the AIIMS in one of the issues of the Indian Journal of Pediatrics by Bakhshi et al[4] on autoimmune hemolytic anemia in association with childhood tuberculosis. In humans, disseminated tuberculosis may occasionally provoke a marked proliferation of reticuloendothelial tissues, resulting in varied and severe hematological disorders through immune mechanisms.[5] Regarding therapy, there are reports in adult literature that hemolysis associated with tuberculosis has responded to antitubercular therapy alone.[6], [7], [8] Steroids are useful in addition to antitubercular therapy if there is severe hemolysis. On the other hand, there is a report of autoimmune hemolytic anemia in association with miliary tuberculosis that required splenectomy.[9]
In view of the known autoimmune associations of tuberculosis such as vasculitis, arteritis and immune thrombocytopenia, and based on the available reports of autoimmune hemolytic anemia in tuberculosis, it is reasonable to suspect and rule out tuberculosis as a possible association in patients with autoimmune hemolytic anemia in children in areas of high endemicity of tuberculosis. This is especially important, as autoimmune hemolytic anemia may require long-term steroid therapy that can aggravate tuberculosis. Physicians should rapidly start antituberculosis therapy once the diagnosis is being made. Caution should also be exercised when selecting rifamycin or para amino salicylic acid for these patients, since both drugs are known to induce hemolytic anemia.[4]
References
1. Gupta V, Bhatia BD. Abdominal tuberculosis with autoimmune hemolytic anemia. Indian J Pediatrics 2005; 72(2) : 175-176.
2. Glasser RM, Walker RI, Hewrion JC. The significance of hematologic abnormalities in patients with tuberculosis. Arch Intern Med 1970; 125: 691-695.
3. Berkowitz FE, Hemolysis and infection: categories and mechanisms of their interrelationship. Rev Infect Dis 1991; 13:1151-1162.
4. Bakhshi S, Rao IS, Jain V, Arya LS. Autoimmune hemolytic anemia complicating disseminated childhood tuberculosis. Indian Journal of Pediatrics 2004; 71 : 549-551.
5. Cameron SJ. Tuberculosis and the blood: a special relationship Tubercle 1974; 55 : 55-57.
6. Murray HW. Transient autoimmune hemolytic anemia and pulmonary tuberculosis. N Engl J Med 1978; 299: 488.
7. Siribaddana S, Wijesundara A. Autoimmune hemolytic anemia responding to antituberculous treatment. Tropical Doctor 1997; 27: 243-244.
8. Kuo PH, Yang PC, Kuo SS, Luh KT. Severe immune hemolytic anemia in disseminated tuberculosis with response to antituberculosis therapy. Chest 2001; 119: 1961-1963.
9. Blanche P, Rigolet A, Massault D, Bouscary D, Dreyfus F, Sicard D. Autoimmune hemolytic anemia revealing miliary tuberculosis. J Infect 2000; 40: 292.(Sahu Jitendra K, Kabra SK)