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Fauchald T, Blomberg B, Reikvam H. Tuberculosis-Associated Hemophagocytic Lymphohistiocytosis: A Review of Current Literature. J Clin Med 2023; 12:5366. [PMID: 37629407 PMCID: PMC10455670 DOI: 10.3390/jcm12165366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/10/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a condition of immune dysregulation and hyperinflammation, leading to organ failure and death. Malignancy, autoimmune conditions, and infections, including Mycobacterium tuberculosis (TB), are all considered triggers of HLH. The aim of this study was to review all reported cases of TB-associated HLH in English literature, and to summarize the epidemiology, diagnostics, treatment, and mortality in patients with concomitant HLH and TB. A systematic review of described cases with TB-associated HLH, via a structured literature search in the medical database PubMed, is presented. Additional articles were included through cross-referencing with existing review articles. Articles were reviewed based on a predetermined set of criteria. A total of 116 patients with TB-associated HLH were identified with a male:female ratio of about 3:2. The age at presentation ranged from 12 days to 83 years. Malignancy, autoimmunity, and renal failure were the most common comorbid conditions. Most patients received both tuberculostatic and specific immunomodulating treatment, which was associated with a 66% (48/73) survival rate compared to 56% (15/27) in those receiving only tuberculostatic treatment, and 0% (0/13) in those receiving only immunomodulating treatment. The survival rate was 55% overall. The overlapping presentation between disseminated TB and HLH poses challenging diagnostics and may delay diagnosis and treatment, leading to increased mortality. TB should be considered as a potential trigger of HLH; clinicians' knowledge and awareness of this may result in the appropriate investigations needed to ensure diagnosis and proper treatment.
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Affiliation(s)
- Trym Fauchald
- Faculty of Medicine, University of Bergen, 5007 Bergen, Norway;
| | - Bjørn Blomberg
- Department of Clinical Science, University of Bergen, 5007 Bergen, Norway;
- Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway
| | - Håkon Reikvam
- Department of Clinical Science, University of Bergen, 5007 Bergen, Norway;
- Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway
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Arslantaş E, Ayçiçek A, Akıcı F, Özkara S, Yılmaz B, Özdemir N, Bayram C. Comparison of bone marrow biopsy and fluorodeoxyglucose-positron emission tomography for the assessment of bone marrow infiltration in children with Hodgkin's lymphoma. Nuklearmedizin 2023; 62:20-26. [PMID: 36746148 DOI: 10.1055/a-1972-9292] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE To compare bone marrow biopsy (BMB) with [18F]-fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography (PET/CT) imaging in the demonstration of bone marrow involvement in children with Hodgkin's Lymphoma (HL) and to investigate the effectiveness of PET/CT imaging and thus the necessity for BMB at staging. METHODS Pediatric patients with HL, who underwent both bilateral iliac BMB and PET/CT imaging at disease staging were retrospectively analyzed. In determining bone marrow involvement (BMinv), BMB and/or first/follow-up PET/CT imaging were eligible for review. RESULTS Fifty-six patients were included. BMinv was detected by PET/CT imaging in 6/56 (10.7%), whereas the proportion was 3/56 (5.3%) in BMB specimens. Bone marrow biopsies and PET/CT images were concordant in 53/56 (94.6%) patients with BMB specimens missing three cases of BMinv detected by PET/CT. When diagnostic accuracy was calculated, sensitivity, specificity, positive predictive value and negative predictive values for PET/CT were 100%, 100%, 100%, 100%, respectively, and the same values for BMB were 50%, 100%, 100%, 94.3%, respectively. CONCLUSIONS The results of PET/CT and BMB for staging of pediatric HL patients were compatible, and PET/CT imaging was found to provide high diagnostic performance in determining BMinv. In keeping with earlier research, the current study showed that BMB may not be necessary in every patient at staging, and should be reserved for cases where PET/CT is inconclusive.
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Affiliation(s)
- Esra Arslantaş
- pediatric hematology oncology, Başakşehir Çam ve Sakura Şehir Hastanesi, Istanbul, Turkey
| | - Ali Ayçiçek
- pediatric hematology oncology, Başakşehir Çam ve Sakura Şehir Hastanesi, Istanbul, Turkey
| | - Ferhan Akıcı
- pediatric hematology oncology, İstanbul Kanuni Sultan Süleyman Eğitim ve Araştırma Hastanesi, Istanbul, Turkey
| | - Selvinaz Özkara
- Pathology, Başakşehir Çam ve Sakura Şehir Hastanesi, Istanbul, Turkey
| | - Burçak Yılmaz
- Nuclear Medicine, Başakşehir Çam ve Sakura Şehir Hastanesi, Istanbul, Turkey
| | - Nihal Özdemir
- pediatric hematology oncology, Istinye Universitesi, Istanbul, Turkey
| | - Cengiz Bayram
- pediatric hematology oncology, Başakşehir Çam ve Sakura Şehir Hastanesi, Istanbul, Turkey
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Poornachandra, Wotiye AB, Ayele BA. Hemophagocytic lymphohistiocytosis: An unusual presentation of disseminated tuberculosis: A case report and literature review. J Clin Tuberc Other Mycobact Dis 2022; 27:100313. [PMID: 35372702 PMCID: PMC8971949 DOI: 10.1016/j.jctube.2022.100313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is an aggressive and life-threatening syndrome associated with cytokine storm. Here, we present a patient with acquired HLH associated with Mycobacterial tuberculosis infection. Case presentation We report a 66-year-old hypertensive and diabetic male patient who presented with four days history of fever and abdominal pain. Denied history of cough and weight loss. Laboratory investigation showed: elevated ferritin, C-reactive protein, and triglyceride. Bone marrow examination showed > 50% hemophagocytosis (RBCs and platelets ingested by macrophages), positive acid-fast bacillus for Mycobacterium tuberculosis bacilli, and no evidence of malignancy. Complete blood count showed anemia and thrombocytopenia. The patient fulfilled six out of eight clinical criterions of the acquired Hemophagocytic lymphohistiocytosis (HLH). The patient was managed with anti-tuberculous medications with adjuvant steroid. On the subsequent days, the patient showed significant clinical improvement and discharged home. However, the patient passed away a week after home discharge. Conclusion The present case highlights on the importance of early diagnosis and treatment of acquired HLH associated with tuberculous infection to improve the clinical outcome of the patient.
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Chen WT, Liu ZC, Li MS, Zhou Y, Liang SJ, Yang Y. Tuberculosis-associated hemophagocytic lymphohistiocytosis misdiagnosed as systemic lupus erythematosus: A case report. World J Clin Cases 2022; 10:3178-3187. [PMID: 35647112 PMCID: PMC9082715 DOI: 10.12998/wjcc.v10.i10.3178] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/10/2021] [Accepted: 02/23/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare disorder with rapid progression and high mortality. HLH occurs mostly due to infection, malignant tumors, and immune disorders. Among infections that cause HLH, viral infections, especially Epstein-Barr virus infections, are common, whereas tuberculosis is rare. Tuberculosis-associated HLH has a wide range of serological and clinical manifestations that are similar to those of systemic lupus erythematosus (SLE).
CASE SUMMARY This study describes a case of tuberculosis-associated HLH misdiagnosed as SLE because of antinuclear antibody (ANA), Smith (Sm) antibody and lupus anticoagulant positivity; leukopenia; thrombocytopenia; pleural effusion; decreased C3, quantitatively increased 24 h urinary protein and fever. The patient was initially treated with glucocorticoids, which resulted in peripheral blood cytopenia and symptom recurrence. Then, caseating granulomas and hemophagocytosis were observed in her bone marrow. She was successfully treated with conventional category 1 antituberculous drugs. In addition, we reviewed the literature on tuberculosis-associated HLH documented in PubMed, including all full-text articles published in English from December 2009 to December 2019, and summarized the key points, including the epidemiology, clinical manifestations, diagnosis, and treatment of tuberculosis-associated HLH and the differences of the present case from previous reports.
CONCLUSION Tuberculosis should be considered in patients with fever or respiratory symptoms. Antituberculous drugs are important for treating tuberculosis-associated HLH.
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Affiliation(s)
- Wen-Ting Chen
- Department of Rheumatology and Clinical Immunology, Army Medical Center, Army Medical University, Chongqing 400000, China
| | - Zhi-Cheng Liu
- Southwest Hospital, Army Medical University, Chongqing 400000, China
| | - Meng-Shan Li
- Department of Rheumatology and Clinical Immunology, Army Medical Center, Army Medical University, Chongqing 400000, China
| | - Ying Zhou
- Department of Rheumatology and Clinical Immunology, Army Medical Center, Army Medical University, Chongqing 400000, China
| | - Shen-Ju Liang
- Department of Rheumatology and Clinical Immunology, Army Medical Center, Army Medical University, Chongqing 400000, China
| | - Yi Yang
- Department of Rheumatology and Clinical Immunology, Army Medical Center, Army Medical University, Chongqing 400000, China
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Increased Risk of Lymphoma in Men or the Elderly Infected with Tuberculosis. Mediterr J Hematol Infect Dis 2021; 13:e2021053. [PMID: 34527205 PMCID: PMC8425346 DOI: 10.4084/mjhid.2021.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 08/11/2021] [Indexed: 12/16/2022] Open
Abstract
Purpose To identify factors associated with lymphoma in patients with prior Mycobacterium tuberculosis infection. Methods A retrospective case-control analysis was performed in a highly tuberculosis (TB)-endemic area. Patients with a history of TB before the diagnosis of lymphoma were retrospectively identified. Inpatients with lymphoma (n=1,057) and pathologically confirmed benign diseases (n=12,916) were consecutively enrolled at Xinjiang Medical University Cancer Hospital between January 2016 and December 2019. Results The proportion of TB infection in patients with lymphoma (n=148, 14.0%) was significantly higher than that in the control (benign diseases) group (n=175, 1.4%) (p<0.0001). The frequencies of TB infection in patients with Hodgkin lymphoma, B-cell non-Hodgkin lymphoma (NHL), and T/NK-cell NHL were 13.6%, 14.6%, and 11.9%, respectively. Relatively high proportions of TB infection were found in patients with chronic lymphocytic leukaemia/small lymphocytic lymphoma (CLL/SLL), marginal zone B-cell lymphoma (MZBL), and diffuse large B-cell lymphoma (DLBCL), at 20.6%, 18.6% and 15.3%, respectively, compared to other subtypes of B-cell NHL. For T/NK-cell NHL, the proportions of TB infection in patients with peripheral T-cell lymphoma, not otherwise specified (PTCL, NOS), and anaplastic large cell lymphoma (ALCL) were 18.2% and 20%, respectively. The multivariate analysis revealed that male sex was an adverse risk factor for lymphoma after tubercular infection. In addition, male sex and older age (>60 years) were associated with B-cell NHL. Conclusion A high proportion of TB infection was found in patients with lymphoma. In TB-infected patients, older age and male sex were associated with susceptibility to lymphoma, suggesting that screening programmes might be useful for the early detection of lymphoma. Keywords Lymphoma; tuberculosis; Burkitt’s lymphoma; diffuse large B lymphoma; Hodgkin’s disease
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Nanthanangkul S, Promthet S, Suwanrungruang K, Santong C, Vatanasapt P. Incidence of and Risk Factors for Tuberculosis among Cancer Patients in Endemic Area: A Regional Cohort Study. Asian Pac J Cancer Prev 2020; 21:2715-2721. [PMID: 32986373 PMCID: PMC7779434 DOI: 10.31557/apjcp.2020.21.9.2715] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Indexed: 11/25/2022] Open
Abstract
Background and Objective: Cancer is a known risk factor for developing active tuberculosis (TB) disease. The incidence of and risk factors for TB are not known among cancer patients in Thailand. This study aimed to investigate risk factors for TB among cancer patients in an area with endemic TB infections. Methods: We used the Khon Kaen population–based cancer registry and two TB databases to conduct a retrospective cohort study of cancer patients. From 2001 to 2015, we identified 40,948 eligible cancer patients. Following until 2017, we identified cases of TB diagnosed after cancer diagnosis and analyzed primary cancer site, staging, treatment, and demographic factors. Adjusted incidence rate ratios (adj. IRR) were computed to identify risk factors among a sub–set of cancer types (n = 9,733) using Poisson regression. Results: Among all cancer patients, 472 cases of TB were diagnosed following cancer diagnosis (cumulative incidence = 1.15%, incidence rate = 421.86 cases per 100,000 patients per year). Among the sub–set of cancer types, 206 cases of TB were found (cumulative incidence = 2.11%, incidence rate = 848.26 cases per 100,000 patients per year). Risk factors for TB among cancer patients were sex (p < 0.001) (male adj. IRR = 1.87, 95% CI: 1.36–2.59), age (p < 0.001) (age >70 adj. IRR = 2.36, 95% CI: 1.56-3.55, compared to age ≤50) and cancer site (p < 0.001). Compared to thyroid cancer, TB infection was more associated with lung cancer without histopathological confirmation (adj. IRR = 6.22, 95% CI: 2.57–15.04). Cancer stage and treatment did not show statistically significant trends. Conclusion: Old age, male sex, and certain cancer types were independent risk factors for TB in cancer patients. Targeted latent TB screening may be appropriate among high risk groups.
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Affiliation(s)
- Sirinya Nanthanangkul
- Doctor of Philosophy Program in Epidemiology and Biostatistics, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand.,ASEAN Cancer Epidemiology and Prevention Research Group, Khon Kaen, Thailand
| | - Supannee Promthet
- ASEAN Cancer Epidemiology and Prevention Research Group, Khon Kaen, Thailand
| | - Krittika Suwanrungruang
- ASEAN Cancer Epidemiology and Prevention Research Group, Khon Kaen, Thailand.,Cancer Unit, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Chalongpon Santong
- Cancer Unit, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Patravoot Vatanasapt
- ASEAN Cancer Epidemiology and Prevention Research Group, Khon Kaen, Thailand.,Cancer Unit, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.,Department of Otorhinolaryngology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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Shao L, Jiang L, Wu S, Yu L, Wang L, Huang X. Simultaneous occurrence of invasive pulmonary aspergillosis and diffuse large B-cell lymphoma: case report and literature review. BMC Cancer 2020; 20:15. [PMID: 31906982 PMCID: PMC6945787 DOI: 10.1186/s12885-019-6471-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 12/17/2019] [Indexed: 11/16/2022] Open
Abstract
Background Patients with lymphoma are at risk for developing pulmonary opportunistic infections due to immunocompromise. However, clinical reports of concurrent lymphoma and opportunistic infection at presentation are rare and often confined to single cases. A delayed diagnosis of either opportunistic infection or lymphoma usually occurs in this complex situation. Here, we report such a case and analyse 18 similar cases searched in the PubMed database to deepen clinicians’ understanding. Case presentation A 48-year-old man presented with a 3-month history of fever, cough and emaciation. High-resolution computed tomography revealed bilateral cavitating lesions of different sizes. Aspergillus fumigatus complex was identified from a bronchoalveolar lavage fluid culture. However, antifungal treatment combined with multiple rounds of antibacterial therapy was unsuccessful, and the patient’s lung lesions continued to deteriorate. Multiple puncture biopsies finally confirmed the coexistence of diffuse large B-cell lymphoma. Despite the initiation of combination chemotherapy, the patient died of progressive respiratory failure. Conclusions Synchronous pulmonary lymphoma and simultaneous opportunistic infection is rare and usually lacks specific clinical and imaging manifestations. Lymphoma should be considered as part of the differential diagnosis of patients with an opportunistic infection when treatment fails or other symptoms are present that could be considered “atypical” for the condition. Tissue biopsy is the gold standard, and multiple biopsies are essential for making the final diagnosis and should be performed upon early suspicion.
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Affiliation(s)
- Lianyou Shao
- Division of Pulmonary Medicine, Key Laboratory of Heart and Lung, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325000, China
| | - Longxiang Jiang
- Division of Pulmonary Medicine, Integrated Chinese and Western Medicine Hospital of Wenzhou, Wenzhou, Zhejiang, 325000, China
| | - Siyao Wu
- Division of Pulmonary Medicine, Key Laboratory of Heart and Lung, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325000, China
| | - Lihua Yu
- Division of Pulmonary Medicine, Key Laboratory of Heart and Lung, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325000, China
| | - Liangxing Wang
- Division of Pulmonary Medicine, Key Laboratory of Heart and Lung, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325000, China.
| | - Xiaoying Huang
- Division of Pulmonary Medicine, Key Laboratory of Heart and Lung, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325000, China.
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Mbizvo GK, Lentell IC, Leen C, Roddie H, Derry CP, Duncan SE, Rannikmäe K. Epilepsia partialis continua complicated by disseminated tuberculosis and hemophagocytic lymphohistiocytosis: a case report. J Med Case Rep 2019; 13:191. [PMID: 31230590 PMCID: PMC6589876 DOI: 10.1186/s13256-019-2092-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 04/18/2019] [Indexed: 11/11/2022] Open
Abstract
Background We describe a patient copresenting with epilepsia partialis continua, tuberculosis, and hemophagocytic lymphohistiocytosis. To our knowledge, this is the first documented case of this triad. Case presentation A 54-year-old black South African woman presented to a hospital in Scotland with an acute history of right-sided facial twitching, breathlessness, and several months of episodic night sweats. Clinical examination revealed pyrexia and continuous, stereotyped, right-sided facial contractions. These worsened with speech and continued through sleep. A clinical diagnosis of epilepsia partialis continua was made, and we provide a video of her seizures. Computed tomographic imaging of the chest and serous fluid analyses were consistent with a diagnosis of disseminated Mycobacterium tuberculosis. An additional diagnosis of hemophagocytic lymphohistiocytosis was made following the identification of pancytopenia and hyperferritinemia in peripheral blood, with hemophagocytosis evident in bone marrow investigation. We provide images of her hematopathology. The patient was extremely unwell and was hospitalized for 6 months, including two admissions to the intensive care unit for ventilatory support. She was treated successfully with high doses of antiepileptic drugs (benzodiazepines, levetiracetam, and phenytoin) and 12 months of oral antituberculosis therapy, and she underwent chemotherapy with 8 weeks of etoposide and dexamethasone for hemophagocytic lymphohistiocytosis, followed by 12 months of cyclosporine and prednisolone. Conclusions This combination of pathologies is unusual, and this case report helps educate clinicians on how such a patient may present and be managed. A lack of evidence surrounding the coexpression of this triad may represent absolute rarity, underdiagnosis, or incomplete case ascertainment due to early death caused by untreated tuberculosis or hemophagocytic lymphohistiocytosis. Further research is needed. Electronic supplementary material The online version of this article (10.1186/s13256-019-2092-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gashirai K Mbizvo
- Muir Maxwell Epilepsy Centre, Centre for Clinical Brain Sciences, The University of Edinburgh, 20 Sylvan Place, Edinburgh, EH9 1UW, UK. .,Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK.
| | - Isabel C Lentell
- Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Clifford Leen
- Regional Infectious Diseases Unit, Western General Hospital, Edinburgh, UK
| | - Huw Roddie
- Department of Haematology, Western General Hospital, Edinburgh, UK
| | - Christopher P Derry
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK.,Department of Clinical Neurosciences and Sleep Medicine, Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Susan E Duncan
- Muir Maxwell Epilepsy Centre, Centre for Clinical Brain Sciences, The University of Edinburgh, 20 Sylvan Place, Edinburgh, EH9 1UW, UK.,Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - Kristiina Rannikmäe
- Forth Valley Royal Hospital, Larbert, and Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
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Jolobe OMP. Timely recognition of hematophagocytosis attributable to coexistence of lymphoma and tuberculosis. QJM 2019; 112:315. [PMID: 30192969 DOI: 10.1093/qjmed/hcy198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- O M P Jolobe
- From the Medical Division, Manchester Medical Society, Simon Building, Brunswick Street, Manchester, UK
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