Tuberculosis presenting as dual immune dysregulation: Evans syndrome and haemophagocytic lymphohistiocytosis.

We report a case of a middle-aged man with no known comorbidities who presented with a 1-month history of fever, dry cough, weight loss and progressively worsening breathlessness.Initial investigations revealed declining haemoglobin, white blood cell and platelet levels, while a chest CT showed diffuse ground-glass opacities and a small pneumothorax. The patient was diagnosed with Evans syndrome (the co-occurrence of warm autoimmune haemolytic anaemia and bicytopenia) after a positive direct Coombs test and other haematological markers. Despite starting steroids, his fever persisted, leading to a further diagnosis of secondary haemophagocytic lymphohistiocytosis (HLH) after fulfilling six of eight HLH-2004 diagnostic criteria. Ultimately, disseminated tuberculosis was identified as the underlying trigger via endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal lymph nodes. The patient successfully recovered following a combined treatment of anti-tubercular therapy and steroids.