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Miliary Tuberculosis in a Crohn's Disease Patient: The Risk beyond the Screening
Liliana Pereira Carvalho1, Maria Ana Túlio1, José Pedro Rodrigues1
1Gastroenterology Department of Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal.
Abstract:
Tumor necrosis factor alpha (TNFα) antagonist is recognized as an effective treatment to achieve clinical remission and healing mucosal in patients with moderate to severe active Crohn's disease. Considering that it plays a central role in immune-mediated modulation, there are some obvious concerns about its long-term safety. There is evidence that it may increase the risk of opportunistic infections such as tuberculosis, particularly reactivation of previous latent infection. Due to the global high incidence of tuberculosis and its frequent severity in immunocompromised patients, the exclusion of latent infection is currently part of the screening prior to anti-TNFα therapy. Only a few cases of life-threatening disseminated tuberculosis have been reported in immunocompromised patients probably related to widespread use of higher-accuracy screening tests, such as interferon-γ release assays. However, despite negative screening, the risk of active tuberculosis infection remains during treatment. In that instance, tuberculosis infection becomes considerably more difficult to diagnose due to its altered pattern presentation (extrapulmonary and disseminated infection) and is harder to treat because of the high rate of resistance and its associated relevant morbidity and mortality. We report an enigmatic case of a miliary tuberculosis despite negative latent infection screening, using interferon-γ release assays, in a Crohn's disease patient undergoing treatment with infliximab and azathioprine, focusing on the screening and diagnostic and therapeutic challenge. This case enhances the awareness of anti-TNFα therapy management and the need for strategies to diagnose and treat tuberculosis in this context.
Insights
Tumor necrosis factor alpha (TNFα) antagonists effectively treat Crohn's disease but carry infection risks. This case highlights the challenge of diagnosing tuberculosis despite negative screening in patients on anti-TNFα therapy.
Area of Science:
- Immunology
- Gastroenterology
- Infectious Diseases
Background:
- Anti-TNFα therapy is crucial for managing moderate-to-severe Crohn's disease, offering clinical remission and mucosal healing.
- TNFα antagonists modulate the immune system, raising concerns about increased susceptibility to opportunistic infections, notably tuberculosis (TB).
- Screening for latent TB infection is standard practice before initiating anti-TNFα therapy due to the high incidence and severity of TB in immunocompromised individuals.
Observation:
- A Crohn's disease patient on infliximab and azathioprine developed miliary tuberculosis.
- The patient had negative screening for latent TB infection using interferon-γ release assays prior to treatment.
- Diagnosis of TB was challenging due to its disseminated and extrapulmonary presentation.
Findings:
- Despite negative latent TB screening, active TB infection can still occur during anti-TNFα therapy.
- Tuberculosis in patients on anti-TNFα therapy presents atypically, complicating diagnosis.
- Treatment of TB in this context is difficult due to drug resistance and associated high morbidity and mortality.
Implications:
- This case underscores the need for heightened awareness regarding TB risk in patients receiving anti-TNFα therapy.
- Current screening methods may not entirely eliminate the risk of active TB infection.
- Developing improved diagnostic and therapeutic strategies for TB in anti-TNFα-treated patients is essential for better patient outcomes.