Abstract: TH-PO853

Hemophagocytic Lymphohistiocytosis Secondary to Tubercular CAPD Peritonitis

Session Information

  • Peritoneal Dialysis - I
    November 02, 2017 | Location: Hall H, Morial Convention Center
    Abstract Time: 10:00 AM - 10:00 AM

Category: Dialysis

  • 608 Peritoneal Dialysis

Authors

  • Dassi, Manisha, Max Super Speciality Hospital, Vaishali, Ghaziabad, Uttar Pradesh, India
  • Aggarwal, Garima, Amrita Insitiute Of Medical Sciences, New Delhi, India
Background

Tubercular CAPD peritontis, though infrequent, has been reported to have a higher incidence in developing countries. HLH, seen in both inherited and secondary forms, is a rare & lethal disorder of the immune system. We report a case of HLH secondary to tubercular CAPD peritonitis.

Methods

A 49 years old male ESRD, on CAPD since 01 year presented with CAPD peritonitis. He required CAPD catheter explantation & shift to HD in view of refractory peritonitis. Though fever resolved, he continued to have clear watery discharge from the poorly healed surgical wound. He was lost to follow up & presented again 03 months later with complaints of fever, weight loss, fatigability and copious amount of yellowish discharge from the surgical wound. Clinically, he was hemodynamically stable, febrile, had pallor, multiple cutaneous ecchymotic spots, hepatosplenomegaly, reduced air entry at right lung base and a 5 cm infra-umbilical midline horizontal poorly healed discharging surgical scar mark with surrounding skin inflammation. Relevant clinical & lab parameters are shown in Table 1. NCCT abdomen revealed hepatosplenomegaly, moderate ascites & loculated fluid collection in the right subphrenic space extending inferiorly into the abdominal & pelvic cavity . Subphrenic fluid aspirate revealed a yellow turbid fluid which was sterile on pyogenic and fungal culture, negative on gram’s, fungal and ZN stains, positive for M tuberculosis on PCR & positive on tubercular culture. Bone marrow asp + biopsy revealed marked degree of histiocytic hemophagocytosis. Patient fulfilled 6/8 criteria for diagnosis of HLH. He was managed with Dexamethasone (6 wks) & ATT (HRZE → HR). He gradually became afebrile with resolution of the infra-umbilical wound discharge, improvement in pancytopenia (Inv at 6 mnths: Hb 11.3 gm%, TLC 4000, Plts 95000/uL) along with improvement in general condition.

Conclusion

HLH should be considered in ESRD patients with tubercular peritonitis in presence of pertinent clinical and lab findings. It has been reported in association with tuberculosis especially extrapulmonary forms. A high index of suspicion is necessary for timely diagnosis & management.

Clinical and Lab Parameters for diagnosis of HLH
HLH Diagnostic CriteriaCriteria fulfilled by Index Patient
1.Fever
2.Splenomegaly
3.Cytopenias (affecting ≥ 2/3 on PBS)
4.Fasting TG ≥ 265 mg/dl and/or fibrinogen ≤ 150 mg/dl
5.Hemophagocytosis in BM or LN or Spleen
6.Ferritin ≥ 500 μg/L
7.Low or absent NK cell activity
8.Soluble CD25 ≥ 2400 U/ml
1.Fever
2.Splenomegaly
3.Hb 5.0 gm/dl, TLC 1800/uL, Plts 45000/uL
4.TG 350 mg/dl
5.Hemophagocytosis (BM)
6.Ferritin 1053 ug/L

HLH Diagnosis based on fulfilment of 5/8 criteria