Challenges in tuberculosis screening before TNF-α inhibitors: A case report highlighting gaps in current practice

We present the case of a 34-year-old Polish man with a history of axial spondyloarthritis and Crohn's disease, who presented with respiratory and neurological symptoms whilst on TNF-α inhibitors treatment. He subsequently developed a fulminant pulmonary tuberculosis (TB) with cerebral involvement. Treatment was complicated by a paradoxical reaction and respiratory failure requiring intensive care admission. This case highlights the diagnostic challenges associated with TB screening prior to immunosuppressive therapy and underscores the limitations of single-test screening protocols. It further emphasizes that, in immunocompromised patients, both IGRA and TST have reduced sensitivity, and a dual testing strategy with repeated, risk-based screening may improve detection in selected high-risk populations. This case also demonstrates that tuberculosis in immunosuppressed patients can follow a fulminant course, and that early detection and timely initiation of appropriate therapy are essential determinants of clinical outcome.