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Case Report Tuberculosis Or Systemic Lupus

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Case Report Tuberculosis Or Systemic Lupus TB OR SLE? A DILEMMA CASE REPORT TUBERCULOSIS OR SYSTEMIC LUPUS ERYTHEMATOSUS? A DIAGNOSTIC AND THERAPEUTIC DILEMMA Asmah Mohd1, Emily ML Goh1, Sook-Khuan Chow1, Lai-Meng Looi2 and Swan-Sim Yeap1 Departments of Medicine1 and Pathology2, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia Abstract. The diagnosis of patients with fever of unknown origin (FUO) is often problematic be- cause the range of possible differential diagnoses is broad. We report on a case in which a patient presented with FUO and was subsequently found to have both a collagen vascular disease and an intercurrent infection. Treatment for the collagen vascular disease with corticosteroids exacerbated the intercurrent infection. The problems in the diagnosis and management of such cases are dis- cussed. Fever of unknown origin (FUO) has been which was not associated with chills, rigors or defined as a temperature of higher than 38.3ºC night sweats. The patient complained of a loss of (recorded repeatedly) that persists for more than appetite, weight loss, recurrent lower abdominal three weeks and that remains undiagnosed despite pain with frequent loose stools. Stools were not one week of inpatient investigations (Petersdorf accompanied by passing out of mucous or bleed- and Beeson, 1961). Making a diagnosis in such ing per rectum. There was no vomiting. Subse- cases remains a challenge as the possibilities are quently, the patient developed painless bilateral numerous. Infections are the commonest cause ankle swelling. of FUO, accounting for 22.5-40% of cases; other He had no significant past medical history common causes are collagen vascular diseases and systemic enquiry was otherwise normal. His (13-21.5%) and neoplasms (7-31%) (Gelfund and grandfather had a history of pulmonary tubercu- Dinarello, 1998). Treatment of such patients is losis. He was a non-smoker, did not drink alco- also difficult as patients with collagen vascular hol and denied any history of unprotected sexual diseases require immunosuppression, which can intercourse. exacerbate occult infections. On physical examination, the patient was We report on a case in which a patient pre- cachectic and dehydrated. He opened his eyes sented with FUO and was subsequently found to spontaneously but was confused and unable to have both a collagen vascular disease and an in- obey commands. He was febrile, 38ºC. He was tercurrent infection. The problems in the diagno- pale but free of jaundice and clubbing; there was sis and management of such cases are discussed. no lymphadenopathy. Old vasculitic lesions over Mr SM, an 18-year-old Indian tile cleaner, his palms, soles and digits were noted. On fundo- presented on the 17th May 2000 with a 6-month scopy, cytoid bodies were seen bilaterally. He had history of progressive weakness and lethargy that oral candidiasis. There was bilateral pitting ankle was associated with myalgia and generalized body edema. Cardiovascular, respiratory and abdomi- pain. He also had an intermittent low grade fever nal examinations were normal. There was no evi- dence of arthritis, rashes, alopecia or oral ulcers. Correspondence: Dr SS Yeap, Department of Medicine, Investigations yielded the following results: Faculty of Medicine, University of Malaya, 50603 hemoglobin 6.5 g/dl, MCV 76 fl, MCH 25.4 pg, Kuala Lumpur, Malaysia. white cell count (WCC) 6.5 x109/l (neutrophils Tel: 603 7950 2867; Fax: 603 7955 7740 81% and lymphocytes 11%), platelets 281x109/l, Vol 34 No. 2 June 2003 361 SOUTHEAST ASIAN J TROP MED PUBLIC HEALTH erythrocyte sedimentation rate (ESR) 76 mm/hr, daily) followed by oral prednisolone (40 mg). His serum albumin 18 g/l [normal range (NR) 35-50], esophageal candidiasis was treated with oral alkaline phosphatase 445 IU/l (NR 30-300), ala- fluconazole (400 mg daily). nine aminotransferase (ALT) 126 IU/l (NR 5-35), His general condition improved and his fe- aspartate aminotransferase (AST) 116 IU/l (NR ver settled after a few days. However, five days 5-35), gamma-glutamyl transpeptidase (γGT) 883 later, his fever recurred. On this occasion, it was IU/l (NR 11-51), total bilirubin 4 µmol/l (NR 3- associated with a productive cough and pain and 17), total cholesterol 5.9 mmol/l (NR 3.6-5.2), swelling of his left ankle and knee. The patient triglycerides 3.5 mmol/l (NR 0.4-1.5), 24-hour had not been in contact with tuberculosis patients urinary protein excretion 3.19 g/dl (NR < 0.5), while he had been in hospital. On examination, serum iron 5.2 µmol/l (NR 9.5-29.9), ferritin he had shotty right anterior cervical lymphaden- 895.2 µg/l (NR 22-322), normal coagulation pro- opathy and coarse crepitations in the lower zone file, complement (C) 3 30 mg/dl (NR 86-184), of the right lung. A repeat chest X-ray showed C4 <10 mg/dl (NR 20-59), anti-nuclear antibody clear lung fields. His left knee and ankle were (ANA) positive 1:320, double-stranded DNA swollen and tender on palpation. 1,893 (NR < 200), IgG 2,040 mg/dl, (NR 931- Aspiration of the left knee recovered blood- 1,916), IgA 438 mg/dl (NR 70-473), IgM 125 mg/ stained synovial fluid with RBC 5,680, WCC 600 dl (NR 34-265). His peripheral blood film showed (polymorphs 80%, lymphocytes 20%); no organ- dimorphic red blood cells. Viral hepatitis sero- isms or crystals were seen. His blood WCC had logy was negative. Fecal occult blood tests were risen to 20x109/l and the CRP was also elevated negative. Urine microscopy showed urine RBC (14.4 mg/dl). No bacterial organisms were cul- 102/µl (NR 0-1), urine WBC 37/µl (NR 0-3) but tured from blood, sputum, or urine; fungal blood no casts or bacteria. Blood, urine and stool cul- cultures were also negative. A repeat abdominal tures were negative. The Weil-Felix test for ty- ultrasound showed no abnormality. However, a phus and the Widal test for Salmonella typhi and repeat echocardiogram showed a small pericar- S. paratyphi were negative. Sputum culture dial effusion. A further chest X-ray (21st June) showed Acinetobacter species. Sputum for acid- showed mild reticular changes which became fast bacilli (AFB) was negative. He was negative more marked after one week. On the 24th June, for HIV-1 antibody. The C-reactive protein (CRP) two samples of sputum were positive for AFB. on admission was <0.8 mg/dl (NR 0.0-0.8). Chest x-ray was normal. Upper gastrointes- He was started on anti-tuberculosis drug tinal endoscopy showed esophageal candidiasis therapy: ethambutol 1g daily, ofloxacin 400 mg with no peptic ulcer disease; abdominal ultra- daily, and clarithromycin 500 mg daily, due to sound was normal. An echocardiogram showed his liver impairment. At the same time, a broad- normal left ventricular function and no vegeta- spectrum antibiotic (imipenam) was given as he tions. remained unwell and febrile. His oral predniso- lone was switched to a small dose of IV hydro- Because of the significant proteinuria and cortisone for adrenal support. active urine sediments, a renal biopsy was per- formed on the 8th June 2000; active diffuse pro- Despite all these measures, his condition liferative lupus nephritis (WHO Class IV) with failed to improve. He continued to have a spik- segmental glomerulitis was reported and marked ing temperature and required ventilatory support tubulointerstitial inflammation and vasculopathy on the 25th June 2000. He then developed dissemi- were also found. A diagnosis of systemic lupus nated intravascular coagulopathy and went into erythematosus (SLE) with renal and skin involve- acute hepato-renal failure despite all supportive ment was made. measures. The patient died on the 27th June 2000. The patient was started on intravenous ampi- Autopsy showed disseminated TB in the lungs, cillin-sulbactam for his Acinetobacter infection; kidneys, liver and spleen. for his lupus nephritis, he was given three days This patient illustrates the diagnostic diffi- of intravenous (IV) methylprednisolone (500 mg culties in FUO. His initial presenting problems 362 Vol 34 No. 2 June 2003 TB OR SLE? A DILEMMA were non-specific, with abdominal symptoms as diagnosis of collagen vascular diseases is gener- well as fever. The fever, alopecia, proteinuria and ally useful, but it is known that chronic infections later the immunological tests, suggested a diag- such as TB can also give rise to elevated autoan- nosis of SLE. However, SLE is much more com- tibody levels. Up to 40% of TB patients can have mon in females and our patient was male. Fever a positive ANA. However, antibodies to double- and weight loss could also be due to TB, espe- stranded DNA are said to occur rarely (< 5%) in cially in a country endemic for TB, such as Ma- patients with TB (Adebajo and Isenberg, 1995). laysia. It has been estimated that the prevalence Our patient’s markedly elevated double-stranded of TB in Southeast Asia is 524 per 100,000, which DNA titer was probably due to his SLE. The is the highest of any region of the world (Dye et American College of Rheumatology has pub- al, 1999). Infections, especially extra-pulmonary lished criteria for the identification of patients TB, remain a leading cause of FUO (Gelfund and with SLE (Tan et al, 1982): a person is said to Dinarello, 1998). Therefore, in this patient, a thor- have SLE if four of the following eleven criteria ough search for TB was made when he was first are present, namely, malar rash, discoid rash, pho- admitted: all the initial investigations were nega- tosensitivity, oral ulcers, arthritis, serositis, renal tive. However, the diagnosis of extra-pulmonary disorder, neurologic disorder, hematologic disor- TB is difficult: miliary or disseminated TB can der, immunologic disorder or presence of ANA.
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