engleski

Atypical clinical course of pulmonary tuberculosis in rheumatoid arthritis patient treated with a TNF-alpha blocker

Introduction of biologics in RA treatment has resulted in some new side effects and comorbidities like TB. The risk of TB during TNFα blockers treatment is higher because of TNFα role in chronic inflammatory processes like forming granulomas and also protecting from TB. Patient with 18-years history of RA has been treated first nine years with different DMARD`s (monotherapy/combination therapy), glucocorticoids and NSAID`s. With all different combinations of DMARD`s, glucocorticoids and NSAID`s RA was still active. Because of that infliximab was added (July 2006) in standard dose and with good response. Afther third application of infliximab patient developed erythema nodosum on legs, without any other signs and symptoms of infection. After complete work-up neither M. tuberculosis (Mantoux test, chest X-ray, bronchoscopy, BAL, catheter aspirate, skin biopsy) or any other infection have been found. Infliximab therapy was reintroduced with good effect. In January 2008 urinary infection with E. coli has been diagnosed and treated. In April 2008 chest X-ray and Mantoux were performed as a part of routine control with normal finding. Three months later patient developed fever and chills, weight loss and malaise without respiratory simptoms. She's been treated with antibiotics for presumed urinary infection with good reponse. One month later another dose of infliximab was applied, and in September 2008 patient was highly febrile again, with weight loss and malaise. New plain chest X-ray was made and the finding was compatibile with milliar TB. M. tuberculosis was found in BAL and sputum directly (and later cultivated) so the standard TB treatment was prescribed. After three months of triple antiTB treatment patient was clinically good with regression of pulmonary infiltrates on X-ray. All specimens were negative so the patient continued profilactic antiTB therapy and standard DMARD and glucocorticoid for repeatedely active RA. Our patient developed miliary TB with atypical clinical course - without respiratory symptoms, normal chest X-ray and Mantoux only 5 months before the diagnosis was proven. With this case report we wanted to highlight the importance of constant awareness with febrile patients treated with TNFα blockers.

Rheumatoid arthritis; tuberculosis; TNF-alpha

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