Immunosuppressive Therapy in Takayasu Arteritis: A Tightrope Walk Between Inflammation and Infection

Infectious diseases like tuberculosis (TB) are highly prevalent in developing countries. Rheumatological diseases are also not uncommon. Both are chronic illnesses with overlapping symptoms and may present a diagnostic challenge. Associations between TB and Takayasu arteritis (TA) have been reported. Immunosuppressive therapy for rheumatological disease always poses a risk of reactivation of infections like TB. Here we report a case of a 12-year-old Indian male child, a known case of TA with bilateral renal artery stenosis on methotrexate, adalimumab, and multiple antihypertensives, who presented with eight days of fever, cough, vomiting, and backache. Initially, the diagnosis of infectious etiology versus disease reactivation was considered. Although on evaluation, septic foci were not identified, and subsequently, pulse methylprednisolone was started. There was some initial improvement, but then the patient deteriorated with a severe headache followed by seizures, altered sensorium, and features of raised intracranial pressure (ICP). Imaging revealed features suggestive of tuberculous meningitis (TBM) with obstructive hydrocephalus, but the cartridge-based nucleic acid amplification test (CBNAAT) was negative in both endotracheal (ET) aspirate and CSF aspirate, leading to a clinico-radiological diagnosis of TBM. He underwent ventriculoperitoneal (VP) shunting and was started on anti-tubercular therapy (ATT). This case emphasizes the need for regular vigilance for infectious risk in rheumatological diseased pediatric populations who are chronically immunosuppressed.