25 February 2026
: Case report 
A 70-Year-Old Woman Receiving Immunosuppressive Therapy Presenting With Iliopsoas Abscess, Pulmonary Miliary Tuberculosis, and Secondary Hemophagocytic Lymphohistiocytosis
Challenging differential diagnosis, Rare coexistence of disease or pathology
Shun Nakahara BE 1, Shunsuke Kondo
ABEF 1*, Christian John Capirig DEF 1, Kazushige Shiraishi E 1, Miho Nakamura E 2, Osamu Hamada EF 3,4
DOI: 10.12659/AJCR.950376
Am J Case Rep 2026; 27:e950376
Table 3 Clinical timeline of events.
| Hospital day | Clinical event |
|---|---|
| Day 0 | Admission with fever, dyspnea, pancytopenia, transaminitis, elevated CRP/ferritin/sIL-2R. Chest X-ray: unremarkable. HRCT: diffuse GGO with septal thickeningAbdominal CT: paraaortic lymphadenopathy and right iliacus low-density lesionT-SPOT.TB: positive. SARS-CoV-2 PCR, HIV, Blood cultures: negative |
| Day 1–3 | CT-guided aspiration of iliacus lesion performed. Gram stain and AFB stain: negativeEmpiric antibiotics initiated (ampicillin-sulbactam, azithromycin)3 sputum AFB smears: negative |
| Day 4 | Worsening respiratory status → mechanical ventilationHRCT: new micronodular opacities. BAL obtained (AFB stain negative, CMV/Pneumocystis PCR negative; culture sent). Mycobacterial cultures from blood, BAL, urine collected |
| Day 10 | Bone marrow biopsy: hemophagocytosis confirmed → HLH diagnosis |
| Day 11 | HLH-94 protocol initiated (dexamethasone 10 mg/m/day, etoposide 150 mg/m) |
| Day 16 | Iliacus aspirate culture: Mycobacterium tuberculosis identified. Mycobacterial cultures from blood, BAL, urine: positive for Mycobacterium tuberculosis → Diagnosis of miliary TB with extrapulmonary involvementStandard anti-TB therapy initiated (Rifampin, Isoniazid, Ethambutol, Pyrazinamide) |
| Days 16–27 | Progressive multi-organ failure despite HLH and anti-TB therapy |
| Day 27 | Death attributed to HLH progression, miliary TB, and possible cytotoxicity from etoposide. Autopsy declined |
| CRP – C-reactive protein; sIL-2R – soluble interleukin-2 receptor; HRCT - high-resolution chest computed tomography; GGO – ground-glass opacity; SARS-CoV-2 – severe acute respiratory syndrome coronavirus 2; PCR – polymerase chain reaction; HIV – human immunodeficiency virus; AFB – acid-fast bacilli; BAL – bronchoalveolar lavage; CMV – cytomegalovirus; HLH – hemophagocytic lymphohistiocytosis; TB – tuberculosis. | |