# Tuberculosis-Associated Hemophagocytic Syndrome Mimicking Malignant Lymphoma: A Case Report

## TL;DR

An elderly man's tuberculosis was initially mistaken for cancer due to similar symptoms and imaging results, highlighting the need for early biopsies to avoid misdiagnosis.

## Contribution

This case report highlights the diagnostic challenge of tuberculosis mimicking malignant lymphoma and emphasizes the importance of early biopsy.

## Key findings

- Tuberculosis-associated hemophagocytic syndrome can present with necrotic lymphadenopathy and high SUVmax values similar to malignancy.
- Lymph node biopsy is crucial for differentiating tuberculosis from cancer.
- Anti-tuberculosis therapy with corticosteroids can reduce systemic inflammation but may not reverse frailty.

## Abstract

A 78-year-old man presented with prolonged fever, weight loss, erythema, and necrotic lymphadenopathy. Initial suspicion of malignant lymphoma-associated hemophagocytic syndrome (HPS) arose from high Fluorodeoxyglucose (FDG) uptake in lymph nodes on PET/CT. However, lymph node biopsy revealed caseous necrosis and granulomas containing acid-fast bacilli, confirming tuberculosis-associated HPS. Diagnosis was delayed due to a negative interferon-gamma release assay and imaging and clinical features resembling malignancy. This case demonstrates that tuberculosis can act as a great mimicker, often presenting similarly to malignancy and complicating diagnosis. Necrotic lymphadenopathy with peripheral enhancement on CT and overlapping Maximum Standardized Uptake Value (SUVmax) values on PET/CT should raise suspicion for tuberculosis in similar cases. Early lymph node biopsy is essential for differentiating tuberculosis from malignancy, ensuring appropriate treatment. Although anti-tuberculosis therapy combined with corticosteroids improved systemic inflammation, the patient’s frailty worsened. This case highlights the importance of considering tuberculosis in the differential diagnosis of systemic inflammation with cytopenia and lymphadenopathy to improve outcomes in severe conditions.