Kaiume Hiroko, Sumi Masahiko, Sato Keijiro, Kirihara Takehiko, Takeda Wataru, Ueki Toshimitsu, Hiroshima Yuki, Watanabe Masahide, Kobayashi Hikaru
Department of Hematology, Nagano Red Cross Hospital.
Department of Hematology, Nagano Prefectural Shinshu Medical Center.
Rinsho Ketsueki. 2019;60(3):203-208. doi: 10.11406/rinketsu.60.203.
An 81-year-old woman with type 2 diabetes mellitus presented to our hospital due to anorexia, leg edema, and respiratory distress. Laboratory results revealed anemia, thrombocytopenia, elevated lactate dehydrogenase, and markedly elevated soluble interleukin-2 receptor levels. Computed tomography showed ground-glass opacities and consolidation in both lung fields, but no lymphadenopathy was noted. Intravascular large B-cell lymphoma (IVLBCL) was considered as a differential diagnosis; therefore, bone marrow and random skin biopsy were performed. Her respiratory condition deteriorated, with the occurrence of acute respiratory distress syndrome, disseminated intravascular coagulation, hemophagocytic syndrome, and further alveolar hemorrhage. Methylprednisolone pulse therapy was performed, but did not improve the patient's condition. On hospital day 6, the acid-fast bacterial smear of the sputum using the Gaffky scale was 2, and on the next day, tuberculosis DNA was detected in the polymerase chain reaction. In the bone marrow biopsy, multiple epithelioid cell granulomas were found; thus, the patient was diagnosed with miliary tuberculosis. Although anti-tuberculosis therapy was started immediately, she died on hospital day 22. The soluble interleukin-2 receptor level increased up to 19,400 U/ml. The differential diagnosis should be cautiously made because miliary tuberculosis can mimic IVLBCL.
一名81岁的2型糖尿病女性因厌食、腿部水肿和呼吸窘迫入住我院。实验室检查结果显示贫血、血小板减少、乳酸脱氢酶升高以及可溶性白细胞介素-2受体水平显著升高。计算机断层扫描显示双肺野磨玻璃影和实变，但未发现淋巴结肿大。血管内大B细胞淋巴瘤（IVLBCL）被列为鉴别诊断；因此，进行了骨髓和随机皮肤活检。她的呼吸状况恶化，出现了急性呼吸窘迫综合征、弥散性血管内凝血、噬血细胞综合征以及进一步的肺泡出血。进行了甲泼尼龙冲击治疗，但患者病情未改善。住院第6天，痰涂片抗酸杆菌用加夫基（Gaffky）分级为2级，次日，聚合酶链反应检测到结核DNA。骨髓活检发现多个上皮样细胞肉芽肿；因此，患者被诊断为粟粒性肺结核。尽管立即开始抗结核治疗，但她于住院第22天死亡。可溶性白细胞介素-2受体水平升至19400 U/ml。由于粟粒性肺结核可模仿IVLBCL，因此应谨慎进行鉴别诊断。
