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No more than meets the eye

  • Author Footnotes
    1 Equally contributed to this work.
    Louis-Philippe Dormegnie
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    1 Equally contributed to this work.
    Affiliations
    Service d'Ophtalmologie. Hôpital Robert Debré. Centre Hospitalier Universitaire Reims. France
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  • Author Footnotes
    1 Equally contributed to this work.
    Adrien Henry
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    1 Equally contributed to this work.
    Affiliations
    Service d'Ophtalmologie. Hôpital Robert Debré. Centre Hospitalier Universitaire Reims. France
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  • Author Footnotes
    2 Equally contributed to this work.
    Jean-Hugues Salmon
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    Affiliations
    Service de Rhumatologie. Hôpital Maison Blanche. Centre Hospitalier Universitaire Reims. France
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    Yohan N'Guyen
    Correspondence
    Corresponding author at: Avenue du général Koenig, 51100 Reims.
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    2 Equally contributed to this work.
    Affiliations
    Service de Médecine Interne, Maladies Infectieuses et Immunologie Clinique. Hôpital Robert Debré. Centre Hospitalier Universitaire Reims. France
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    2 Equally contributed to this work.
Published:April 01, 2021DOI:https://doi.org/10.1016/j.ejim.2021.03.022

      1. Main section (case description)

      A 33-year old Ivorian woman was admitted for fever and thrombocytopenia. She had been previously treated in France by tocilizumab then anti TNF-α for rheumatoid arthritis since 7 and 2 years respectively. She lost weight three months ago, whereas her last trip to Ivory Coast was three years ago. Physical examination was unremarkable except a hectic fever. Complete Blood count revealed hypochromic microcytic anaemia (6.1 g/dL) and profound thrombocytopenia (11 000/mm3), Serum C reactive protein and ferritin values were 81 mg/L and 636 ng/mL respectively. Haemoglobin level was corrected whereas platelets level was not, once red blood cells and platelet transfusion had been performed. Bone marrow cytology was normal with presence of megakaryocytes. Platelet associated immunoglobulins were detected by flow cytometry and ELISA (anti GPIIb/IIIa and anti GPIa/IIa). Computerized tomography scan yielded multiple micronodules of lungs, spleen and liver associated with mesenteric lymphadenopathies (Fig. 1A). Funduscopy revealed a single elevated yellowish-white choroidal lesion of the left eye with fluorescein angiographic signs of exudation (Fig. 1B).
      Fig. 1
      Fig. 1A. Above: Computerized tomography scan of the lungs in the coronal plane showing multiple micronodules of both lungs. Below: Computerized tomography scan of the abdomen in the coronal plane showing nodules of spleen and liver associated with a mesenteric lymphadenopathy. B. Above: Funduscopy of the left eye showing a single elevated yellowish-white choroidal lesion. Below: Fluorescein angiography showing exudation of the choroidal lesion.
      Question: What is the most plausible diagnosis?

      2. Discussion section (225 words)

      Culture of Broncho-alveolar fluid grew a fully sensitive Mycobacterium Tuberculosis strain and the diagnosis of miliary Tuberculosis with choroidal Tuberculoma associated with immune thrombocytopenia was retained.
      The multiple micronodules in both lungs were consistent with the millet-seed like appearance observed during miliary Tuberculosis, which is a subset of disseminated Tuberculosis. Although less evocative than Choroidal Tubercles (usually multiples, grayish, surrounded by inflammation, with a size inferior to 0.5 disc diameter), the presence here of a choroidal Tuberculoma (always single, yellowish, with exudative detachment and larger size) suggested also strongly Tuberculosis. It has been described during miliary and disseminated Tuberculosis [
      • Annamalai R.
      • Biswas J.
      Bilateral choroidal tuberculoma in miliary tuberculosis - report of a case.
      ], which were overrepresented (in 5 to 40% of cases) amongst patients treated by anti TNF-α [
      • Baronnet L.
      • Barnetche T.
      • Kahn V.
      • Lacoin C.
      • Richez C.
      • Schaeverbeke T.
      Incidence of tuberculosis in patients with rheumatoid arthritis. A systematic literature review.
      ]. Systematic funduscopy evidencing Choroidal Tuberculoma allowed here to make (before culture) the diagnosis of Tuberculosis, which is infrequently associated with Immune Thrombocytopenia. Indeed, Immune Thrombocytopenia has only been described in more than 50 cases of all kinds of Tuberculosis so far [
      • Weber S.F.
      • Bélard S.
      • Rai S.
      • Reddy R.
      • Belurkar S.
      • Saravu K.
      Immune thrombocytopenia secondary to tuberculosis: a case and review of literature.
      ].
      Our patient received 12 months of antimycobacterial therapy associated with Corticosteroids because of immune thrombocytopenia. Corticosteroids treatment lasted 4 months because of subsequent Rheumatoid Arthritis flare-ups, which then led to the reintroduction of Etanercept. After the end of antimycobacterial therapy, all micronodules and choroidal tuberculoma had vanished as well as the patient gained all the weight she had lost and did not experience fever or thrombocytopenia recurrence.

      Declaration of Competing Interest

      None.

      Acknowledgement

      The authors report no source of funding.

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