Beyond Lungs: Hematuria as the Primary Presentation of Immune Thrombocytopenic Purpura in Case of Extrapulmonary Tuberculosis Complicated with Rifampicin-induced Thrombocytopenia Posing Diagnostic and Therapeutic Challenge

Tuberculosis (TB) is a significant cause of mortality globally and can affect various organ systems, leading to diverse clinical presentations. The hematological presentation of TB as symptomatic thrombocytopenia, leukopenia, and pancytopenia is exceedingly rare. Antitubercular therapy (ATT) is an effective treatment, but it can have hematological side effects such as anemia and thrombocytopenia, apart from systemic toxicities. Noncompliance and treatment failure are common with long-term use of ATT. We report a case of a 55-year-old man who presented in hypovolemic shock caused by sudden-onset hematuria as a consequence of thrombocytopenia (platelet count of 2,000 cells/mm 3 ), mainly attributed to immune thrombocytopenic purpura (ITP), which was secondary to extrapulmonary tuberculosis (EPTB) pleural effusion. The patient responded moderately to treatment with steroids, platelet transfusions, and romiplostim. The rise in platelet counts and subsequent resolution of symptoms augmented after the institution of ATT. Upon normalization of platelet counts, regular ATT was started, but after a week, his platelets decreased again due to rifampicin-induced thrombocytopenia, requiring treatment modification. We also encountered hyperuricemia, which led to bilateral lower limb cellulitis caused by pyrazinamide, necessitating its withdrawal. This case highlights the importance of monitoring hematological parameters during ATT to prevent drug-induced adverse effects, especially in cases where ITP masquerades as TB. In summary, TB and antitubercular drugs can have hematological manifestations, which makes it very challenging to diagnose and treat and requires frequent monitoring of hematological parameters. This adverse event leads to eventual nonadherence to drugs and treatment failure and can be fatal.