What causes purpura and nosebleeds during TB treatment?

Question

Hi doctor,

My mom is 57 years old. She was diagnosed with TB disease two months back through exclusion, as her tests were negative, but she had enlarged lymph nodes in the chest, low fever, night sweats, etc. The biopsy was negative for lymphoma and sarcoma.

She started ATT medicine, and after 10 days, she got rashes, so the doctor stopped it. After 10 days, she was restarted with ATT, and suddenly she got purpura and bleeding from the nose and cough. She was taken for tests, where her platelets came back as 10000.

It has been 12 days, and she has been on steroids as SOS and Rivolade (past 3 days), but the platelets are still below 10000, and RBC and Hb are also dropping. She is bleeding through urine and stool. Her other tests are normal, including the bone marrow biopsy. Attaching her latest report.

Please advise.

Answer 1

Hello,

Welcome to icliniq.com.

According to your history, ITP (idiopathic thrombocytopenic purpura) might come under suspicion. But you do not have ITP, as bone marrow is normal, and megakaryocytes are not showing any sign of ITP.

Check for hypersplenism by USG (ultrasound) abdomen investigation. Second, rule out dengue by IgM dengue testing (ELISA or card test). Check your kidney profile investigation for serum urea, creatinine, etc. Blood infections have to be ruled out, like septicemia, by blood culture.

Your bleeding and all other complaints are because of low platelets. Low platelets with bleeding need transfusion of platelets in the form of SDP or random donor platelets.

Hence, first rule out all the above causes if present, and then if no cause is found, we have to strongly suspect autoimmune hemolytic anemia because of your CBC report (attachment removed to protect patient identity), showing normoblast and high reticulocyte count. And for that, further investigation is done with DCT (direct Coombs test) and other suitable workups.

Steroids are needed if DCT is positive and autoimmune hemolytic anemia is confirmed.

I hope this helps.

Thank you.