Disseminated Tuberculosis With Ocular Involvement After 12 Years of Anti-TNF-α Therapy

Ocular tuberculosis (TB) is an uncommon yet potentially vision-threatening manifestation of Mycobacterium tuberculosis, particularly difficult to diagnose in immunocompromised individuals. The increasing use of anti-tumor necrosis factor-α (anti-TNF-α) agents has markedly heightened the risk of TB reactivation, often with disseminated or extrapulmonary involvement despite negative baseline screening.

We describe a 52-year-old woman with rheumatoid arthritis receiving long-term adalimumab and methotrexate who developed disseminated TB with pulmonary, splenic, and ocular involvement after 12 years of anti-TNF-α therapy. Baseline screening had shown a negative tuberculin skin test and an indeterminate interferon-γ release assay. She presented with constitutional and respiratory symptoms, whereas chest computed tomography demonstrated diffuse micronodular infiltrates consistent with miliary TB. Microbiological confirmation was obtained via bronchoalveolar lavage. Ophthalmologic evaluation revealed bilateral choroidal granulomas with subretinal edema, leading to a diagnosis of ocular TB. Standard antitubercular therapy (ATT) was initiated but required modification due to drug-induced liver injury. Adjunctive systemic corticosteroids were introduced after antimicrobial therapy and gradually tapered. The patient achieved progressive clinical, radiological, and ophthalmologic improvement, with gradual regression of choroidal lesions.

This case underscores the persistent long-term risk of TB reactivation during prolonged anti-TNF-α therapy and highlights the limitations of current screening strategies in immunosuppressed patients. Ocular TB requires integration of systemic, clinical, and imaging findings; in this patient, microbiologically confirmed disseminated TB together with characteristic bilateral choroidal granulomas supported a definitive diagnosis. Management relies on prompt ATT, discontinuation of immunosuppression, and judicious use of adjunctive corticosteroids. Long-term follow-up is essential given the risk of persistent lesions and late recurrence. Reintroduction of biologic therapy may be feasible in selected cases but requires careful risk stratification.

TB should remain a diagnostic consideration in patients receiving biologic therapy who develop compatible systemic or ocular manifestations, even after long-term treatment and negative baseline screening. Close multidisciplinary collaboration is essential for the diagnosis and management of ocular TB in this population.