Case Report

A Case Report of 56 years old male with AIHA Mixed Type, Pulmonary TB on
treatment with modification, Hepatitis Caused by Drug Induced Liver Injury.

Okky Winang Saktyawan1 Suyono2

1
Internal Disease Resident, RSUP Dr. Kariadi Semarang

2
Internal Disease Staff, Medical Hematology-Oncoloy Division, RSUP Dr. Kariadi Semarang

Abstract
Introduction:
The diagnosis of mixed-type autoimmune haemolytic anaemia (AIHA) is based on
demonstrating the presence of "warm" IgG auto-antibody and "cold" IgM auto-antibody (with
low titre, high thermal amplitude, reacting at, or above, 30°C). Mixed-type AIHA is rare and
can be idiopathic or secondary, such as Tuberculosis (TB). Tuberculosis (TB) is an infectious
disease caused by Mycobacterium tuberculosis (MTB) bacteria, generally affects the lungs.
TB DILI is a disorder of liver function due to the use of antituberculosis drugs (ATD). DILI
due to ATD occurs within 2 months after administration and the highest incidence occurs in
the first 2 weeks.
Case Illustration:
A 56-year-old man is being treated at RSUP Dr. Kariadi with severe normochromic
normocytic anemia (Hb 2.9; MCH 33.3; MCV 90), after the Direct Coomb Test, it was found
+3. Furthermore, the patient was tested for agglutination, and the cold and warm agglutinins
were positive. So this patient is included in the Mixed type AIHA. Subsequently, the patients
were treated with maintenance therapy with Mycophenolic Acid 2X360 mg,
Methylprednisolone 3x4 mg, and Cyclosporin A 4x50 mg. Up to 8 months of treatment the
patient came complaining of a cough for 2 weeks. Thorax X-ray was performed to obtain
bronchopneumonia, then the patient underwent MSCT Thorax. Infiltrates were found in both
lung fields with bronchopneumonia. Patient underwent, Bronchoscopy, sputum examination
and TCM were performed and Mtb Detected, Rifampicin Sensitive. The patient was treated
with the INH regimen, Rifampicin and Ethambutol, (Z was not given from the beginning
because the total bilirubin was 5.0 mg/dL), monitoring for 3 days, the patient complained of
nausea and vomiting and the total bilirubin rose to 9.0 mg/dL. After rechallenge therapy, the
patient is severely allergic to Rifampicin, INH, Pyrazinamide, so it is necessary to give
Levofloxacin, Ethambutol and Clofazimine.
Discussion:
Severe normochromic and normocytic anaemia with history receiving blood transfusion
present with positive direct coomb test with warm and cold agglutinin. These finding results
in mix type AIHA diagnosis being upheld. While the main etiology of the disease remains
unclear, we believe that secondary infection, in this case Tuberculosis infection, may induce
AIHA. On the other site, AIHA-related drugs could induce Tuberculosis by lowering the
immune system, so that the body prone to Mycobacterium tuberculosis infection.
Conclusion :
Autoimmune Haemolytic Anaemia (AIHA) is one of the rarest diseases in the world. It
affects 1-3 person every 100.000 world populations. While the mechanism of the disease
remains unclear, AIHA could have relationship with other diseases such as Tuberculosis
(TB). Drug-induced liver injury (DILI) is a form of side effect that causes the cessation of TB
treatment or regimen changes due to treatment failure, relapse, or resistance. TB treatments
that are known to cause DILI are INH, rifampicin, and pyrazinamide.

Keywords: autoimmune, hepatitis, anaemia, tuberculosis, DILI

Seorang Pria 56 Tahun Menderita Mixed Type AIHA, TB Paru Terkonfirmasi
Bakteriologis on OAT Kategori 1 Modifikasi, Hepatitis akibat Drug Induced Liver
Injury

Abstrak
Pendahuluan:

Ilustrasi Kasus:
Laki-laki 56 tahun dirawat di RSUP Dr. Kariadi dengan anemia berat normositik
normokromik (Hb 2.9 ; MCH 33.3 ; MCV 90), setelah dilakukan pemeriksaan Direct Coomb
Test didapatkan +3. Selanjutnya Pasien dilakukan tes aglutinasi didapatkan Cold and Warm
Aglutinin positif. Maka Pasien ini termasuk dalam Mixed type AIHA. Selanjutnya Pasien
pasien diterapi rumatan dengan Mycophenolic Acid 2X360 mg, Metilprednisolon 3x4 mg,
dan Siklosporin A 4x50 mg. Sampai 8 Bulan pegobatan pasien datang mengeluh batuk
selama 2 minggu, dengan dahak sulit keluar. Dilakukan Rontgen Thorax didapatkan
gambaran bronkopneumonia, selanjutnya Pasien dilakukan MSCT Thorax didapatkan infiltrat
pada kedua lapang paru dengan gambaran Bronkopneumonia. Selanjutnya dilakukan
Bronkoskopi, dilakukan pemeriksaaan Sputum dan TCM didapatkan Mtb Detected,
Rifampisin Sensitive. Pasien dilakukan Pengobatan dengan regimen INH, Rifampisin dan
Etambutol, (Z tidak diberikan dari awal karena bilirubin total 5.0 mg/dL), pemantauan selama
3 hari, pasien mengeluh mual dan muntah dan bilirubin total naik menjadi 9.0 mg/dL. Setelah
dilakukan rechallenge terapi, pasien alergi berat terhadap Rifampisin, INH, Pirazinamid,
sehingga perlu diberikan Levofloksasin, Etambutol dan Klofazimin.
Diskusi: