Tuberculosis the great masquerader

With increased use of disease-modifying antirheumatic drugs, screening for latent tuberculosis infection is more important than ever. However, even with appropriate screening, reactivation of tuberculosis can occur in patients who have had significant epidemiological exposures. Herein, we present a case of a seventy-four-year-old woman with severe rheumatoid arthritis on long-term disease-modifying antirheumatic drugs who developed cryptic miliary tuberculosis. Histopathological findings from an abdominal lymph node biopsy showed caseating granulomas which were initially attributed to her rheumatoid arthritis given screening tests and sputum acid-fast cultures were negative for tuberculosis. It was not until tuberculosis spondylitis developed that the diagnosis was finally elucidated. This case highlights the need for clinicians to be vigilant about discussing historical epidemiological exposures to tuberculosis instead of relying solely on screening testing.