A Rare Initial Presentation in Extra Pulmonary Tuberculosis- Hemophagocytic Lymphohistiocytosis as a Differential Diagnosis

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disorder characterized by excessive activation of the immune system leading to tissue damage and organ dysfunction. We present a case of HLH Like initial presentation secondary to extrapulmonary tuberculosis (TB) in a young male who presented with fever, constitutional symptoms and generalized lymphadenopathy. Initial presentation of this case there were no much evidence to suggest extrapulmonary tuberculosis, but few months later he presented with a lymphocytic exudative pleural effusion with high Adenosine Deaminase (ADA) level and patient improved with antituberculosis treatment(ATT). Initial presentation of this case there are some features favouring HLH but not fulfilling the required criteria for diagnosis based on our Sri Lankan setting, but HLH can be considered as the most probable differential diagnosis while discussing others. This presentation emphasizes importance of high degree of suspicion of tuberculosis as the underlying etiology for Pyrexia of Unknown Origin (PUO) with atypical clinical findings with high inflammatory response.