Hepatitis B Leading to Megaloblastic Anemia and Catastrophic Peripheral Thrombocytopenia

Hepatitis B virus (HBV) typically causes chronic hepatitis, cirrhosis, and hepatocellular carcinoma. It is associated with a variety of extrahepatic complications. We herein, present a rare extrahepatic complication of HBV infection. A 32-year man presented with melena, bleeding from gums and fever. Peripheral blood examination revealed anemia, macrocytosis and severe thrombocytopenia. His hepatitis B surface antigen (HBsAg) was positive but deoxyribonucleic acid (HBV DNA) by polymerase chain reaction (PCR) was negative. Other hepatitis, human immune deficiency virus (HIV), dengue, and autoimmune serology were negative. Bone marrow examination revealed megaloblastic erythropoiesis. There was mild to moderate reduction of megakaryocytes in bone marrow, which was not compatible with severe peripheral thrombocytopenia. His response to cyanocobalamin and folic acid was remarkable for myeloid cell lines and moderate for erythroid cell lines, but poor to platelet counts. Platelet counts gradually improved to safe limits with eltrombopag, likely reflecting autoimmune pathogenesis for thrombocytopenia. This case report highlights multiple targets of HBV infection with associated multiple pathogenetic mechanisms.

PREGNANCY, THYROTOXICOSIS AND POLYMYOSITIS

A young pregnant lady of 26 years age, presented with recent onset weaKness of legs. On examination, she was only able to move legs from side to side and lift the arms with difficulty. Rest of neurological and systemic examination did not reveal any abnormality. On investigations, there were raised serum muscle enzyme levels, hyperthyroid hormone profile, myopathy on electromyography and myositis on muscle biopsy. Common conditions of myositis were excluded. She was given glucocorticoids and methimazole to which she responded well.