Abstract
High ferritin levels have been found to be associated with non infectious as well as infectious causes including tuberculosis. This is one case report of 41 year old male who presented with cough with expectoration. The patient had Multi drug resistant tuberculosis (MDRTB) and type 2 diabetes mellitus. The laboratory findings showed Iron 280 μg/dl, Total iron binding capacity (TIBC) 61 μg/dl, and ferritin 92,945 ng/ml which indicates that iron is an essential nutrient for the survival of the pathogen Mycobacterium tuberculosis.
Keywords: Ferritin, TIBC, MDRTB
Introduction
Ferritin plays an essential role in iron homeostasis by binding and sequestering intracellular iron. It acts as an acute-phase reactant, and elevated levels are typically associated with both acute and chronic inflammatory conditions [1]. Markedly elevated levels of ferritin have been associated with various non-infectious causes, including malignancies, severe iron overload, and dialysis-dependent chronic renal failure [2, 3]. Infectious causes are disseminated histoplasmosis and pulmonary tuberculosis [4, 5]. Here is one case report of hyperferrtinemia seen in pulmonary tuberculosis.
Case Report
A 41 year old male presented with cough with expectoration, facial puffiness and pedal edema since 2 days. Past history is suggestive of type 2 diabetes mellitus and multidrug resistant tuberculosis (MDRTB). Patient was on insulin therapy. On physical examination positive findings were icterus+, pallor+, bilateral crepitation all over lung field, and hepatomegaly. Laboratory findings showed AFB stain +ve, haemoglobin 6.1 gm/dl, platelet count 107000 cells/cmm, ESR 103 mm/hr, AST 3059 U/L, ALT 360U/L, Iron 280 μg/dl, TIBC 61 μg/dl, and ferritin 92,945 ng/ml. Ferritin was estimated by Electro Chemiluminescence assay in a NABL (National accreditation board for testing and calibration laboratories) accreditated laboratory. Ferritin estimation was repeated twice in the laboratory. Radiography and ultrasonographic picture of chest were suggestive of bilateral pleural effusion. Patient was diagnosed as multi drug resistant pulmonary tuberculosis (MDRTB), with pleural effusion, hyperferritinemia and started with second line antituberculosis treatment.
Discussion
Iron is an essential nutrient for almost all microbes, including pathogens such as Mycobacterium tuberculosis. Iron is one of the crucial elements required for the growth of M. tuberculosis. However, excess free iron becomes toxic for the cells because it catalyzes the production of reactive oxygen radicals, leading to oxidative damage. Hence it is essential for the pathogen to have the ability to store intracellular iron in an iron-rich environment and utilize it under iron depletion [6]. M. tuberculosis has iron storage protein ferritin. Some studies have reported that hyperferritinemia is associated with M. tuberculosis [7]. We therefore conclude that M. tuberculosis may be the most important cause for severe hyperferritenemia.
Conclusion
This study concludes that infection with M. tuberculosis may be associated with very high levels of ferritin.
References
- 1.Camaschella C, Poggiali E. Towards explaining ‘‘unexplained hyperferritinaemia’’. Haematologica. 2009;94:307–309. doi: 10.3324/haematol.2008.005405. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Hearnshaw S, Thompson N, McGill A. The epidemiology of hyperferritinaemia. World J Gastroenterol. 2006;12:5866–5869. doi: 10.3748/wjg.v12.i36.5866. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Baynes R, Bezwoda W, Bothwell T, Khan Q, Manssor N. The non-immune inflammatory response: serial changes in plasma iron, iron binding capacity, lactoferrin, ferritin and C-reactive protein. Scand J Clin Lab Investig. 1986;46:695–704. doi: 10.3109/00365518609083733. [DOI] [PubMed] [Google Scholar]
- 4.Bayes B, ROmeu J, Vaquero M, Ribera M, Navarro JT, Rosell A, et al. Disseminated histoplasmosis and AIDS. Report of 4 cases. Med Clin (Barc) 1996;106:700–703. [PubMed] [Google Scholar]
- 5.Koduri P, Chundi V, Mizock B, DeMarais P, Patel A, Weinstein R. Reactive hemophagocytic syndrome: a new presentation of disseminated histoplasmosis in patients with AIDS. Clin Infect Dis. 1995;21:1463–1465. doi: 10.1093/clinids/21.6.1463. [DOI] [PubMed] [Google Scholar]
- 6.Vineel PR, Rupangi VP, Aparna K, Anil KT. Iron storage proteins are essential for the survival and pathogenesis of Mycobacterium tuberculosis in THP-1 macrophages and the guinea pig model of infection. J Bacteriology. 2012;194:567–575. doi:10.1128/JB.05553-11. [DOI] [PMC free article] [PubMed]
- 7.Adele V, van de Vyer A. Severe hyperferritinemia in Mycobacteria tuberculosis infection. Clin Infect Dis. 2011;52:273. doi: 10.1093/cid/ciq126. [DOI] [PubMed] [Google Scholar]