A 70-Year-Old Woman Receiving Immunosuppressive Therapy Presenting With Iliopsoas Abscess, Pulmonary Miliary Tuberculosis, and Secondary Hemophagocytic Lymphohistiocytosis

BACKGROUND Miliary tuberculosis (TB) carries an increased risk in immunosuppressed patients. Extrapulmonary manifestations include hemophagocytic lymphohistiocytosis (HLH) and iliopsoas abscess. The coexistence of multiple extrapulmonary involvements can result in a significant diagnostic challenge. In the treatment of TB-associated HLH, the use of immunosuppressive agents remains controversial because of the risk of exacerbating TB. This report describes the case of a 70-year-old woman with rheumatoid arthritis presenting with an iliopsoas abscess, pulmonary miliary tuberculosis, and secondary HLH. CASE REPORT A 70-year-old Japanese woman with a history of rheumatoid arthritis treated with immunosuppressive therapy including golimumab and iguratimod presented with fever, dyspnea, cough, and weight loss. Imaging demonstrated an iliacus muscle abscess and possible pulmonary miliary tuberculosis. Clinical manifestations, laboratory findings, and bone marrow biopsy results were consistent with a diagnosis of HLH. Acid-fast bacilli cultures were positive for Mycobacterium tuberculosis from the abscess, bronchoalveolar lavage fluid, urine, and blood, confirming the diagnosis of miliary TB. The patient received the HLH-94 treatment protocol and antituberculosis therapy for TB-associated HLH, but unfortunately died of multi-organ failure. CONCLUSIONS In immunosuppressed patients presenting with multi-organ involvement, such as iliopsoas abscess and HLH, clinicians should maintain a high index of suspicion for miliary TB and pursue proactive diagnostic evaluation. Given the limited evidence supporting immunomodulatory therapies in TB-associated HLH, management should be individualized and guided by multidisciplinary discussion.