View Abstract

A6951 - Systemic Tuberculosis in a Patient on Anti-TNF Therapy
Author Block: P. Trivedi1, A. Magh2, A. Adial3; 1Medicine, New York Presbyterian/Queens, Flushing, NY, United States, 2New York Presbyterian/Queens, Flushing, NY, United States, 3New York Presbyterian/Queens, Flushing, NJ, United States.
Introduction: Active tuberculosis is a known complication of TNF-alpha inhibitor (Anti-TNF) therapy. Patients are required to be tested for latent Tuberculosis (TB) prior to initiation of therapy. If results of screening test are positive, patients are treated with either INH or a combination of INH and rifampin prior to starting anti-TNF therapy. We present a case of a patient with latent TB who developed systemic tuberculosis despite appropriate chemoprophylaxis with isoniazid after being started on infliximab. Case Presentation: 61 year old man with Rheumatoid arthritis on Infliximab therapy, which was started after treatment for latent TB with INH for 9 months, presented to the hospital with shortness of breath, fever, cough, night sweats and weight loss of 10-12lbs for the past three months. On CT of the chest patient was found to have multiple, diffuse, small nodular opacities. CT of the abdomen revealed complex ascites w/ proteinaceous, soft tissue stranding and nodularity, retroperitoneal lymphadenopathy, and hepatic lesions. Additionally patient was noted to have testicular swelling for which ultrasound revealed epididymitis. Sputum for AFB and NAAT testing were positive for tuberculosis and patient was subsequently started on RIPE therapy for active miliary and disseminated tuberculosis. Discussion: TNF-alpha inhibitors (Anti-TNF) used in the treatment of Rheumatoid arthritis (RA) have been shown to increase risk of tuberculosis (TB) reactivation in patients with latent disease. Reactivation of latent TB is secondary to loss of granuloma integrity mediated by a variety of mechanisms including inhibition of phagolysosome maturation and interference of T cell function. Prior to starting an Anti-TNF, patients are screened for latent TB by either the Tuberculin skin test (TBT) or the T-cell interferon-gamma release assay (IGRA).
Patients that are positive for latent TB are treated with several different regimens including Isoniazid for nine months or a combination of Isoniazid and Rifampin for three-four months. Our patient was treated with INH for 9 months and despite this developed systemic TB. Treatment with Isoniazid for nine months has shown to be 65-75% effective in compliant patients. In a large-scale retrospective study of TB reactivation in patients being treated with Anti-TNF by Sichletidis in 2006, 19.4% of patients who completed chemoprophylaxis prior to starting an Anti-TNF had reactivation of tuberculosis. Of the patients who had reactivation of TB, all had pulmonary disease; none had diffuse manifestations as our patient.