TUBERCULOUS PLEURAL EFFUSION MASQUERADING AS DRUG-INDUCED LUPUS
Chest
; 162(4):A365, 2022.
Article
in English
| EMBASE | ID: covidwho-2060575
ABSTRACT
SESSION TITLE Critical Care Presentations of TB SESSION TYPE Rapid Fire Case Reports PRESENTED ON 10/18/2022 1225 pm - 0125 pm INTRODUCTION:
TNFα plays a pivotal role in inflammation and maintenance of immune response against tuberculosis. The use of TNF inhibitors (TNFi) is associated with a significant increase in the incidence of tuberculosis (TB). TNFi may cause drug-induced lupus (ATIL) presenting as constitutional symptoms, rashes, pericardial and pleural effusions with positive autoantibodies. We present a case of pleural TB masquerading as drug-induced lupus. CASE PRESENTATION A 68y/o woman with a history of ulcerative colitis (on infliximab, mesalamine), hypertension, T2DM, CAD, complained of low-grade fever, rashes, left-sided chest pain, dyspnea, and arthralgias for two weeks. Chest pain- worse with inspiration and cough. She emigrated from India to the USA 40 years ago. Six months before infliximab therapy, Quantiferon gold was negative. Exam faint hyperpigmentation over shins, minimal swelling of MCPs and ankles, dullness to percussion over the left chest with decreased breath sounds. Labs CRP 101 mg/dL, Hb 10.8 iron deficient, rheumatoid factor and anti-CCP negative, ANA 140, dsDNA 1640, a reminder of ENA negative, anti-histone negative, C3/C4 normal, UA bland, protein/Cr 0.4 mg/gm, negative blood cultures, SPEP and LDH normal. CXR opacification of the left lung up to midfield. CT chest moderate left and small right pleural effusions, enlarged mediastinal lymph nodes. COVID and Quantiferon negative. Thoracentesis 850 ml of exudative fluid (2 out of 3 Light's criteria), lymphocytic predominance (76% of 4148 nucleated cells), adenosine deaminase (ADA) 42 U/L, gram stain, culture, acid-fast and MTB PCR negative, cytology negative. Thoracoscopy with biopsy of the parietal pleura necrotizing granulomatous pleuritis with acid-fast bacilli. Sensitivity pan-sensitive M. tuberculosis. Sputum negative for TB. She was discharged on RIPE treatment for reactivation of TB.DISCUSSION:
The incidence of infliximab-induced lupus is approximately 0.19% and confirming the diagnosis is challenging. The immunogenicity of infliximab is high, 66% of patients develop positive ANA. Anti-histone antibodies are less commonly associated with ATIL as opposed to classic drug-induced lupus and dsDNA is positive in up to 90% of cases of ATIL. Renal involvement is rare. The diagnostic usefulness of ADA (over 40 U/L) in lymphocytic pleural effusions for the diagnosis of tuberculosis in an immunosuppressed individual is demonstrated here. In countries with low TB burden, such as the USA, the positive predictive value of ADA in pleural fluid declines but the negative predictive value remains high.CONCLUSIONS:
Tuberculous pleuritis is not always easily diagnosed since AFB smears and sputum may remain negative. When ADA level in lymphocytic pleural fluid is not low thorough search for TB with thoracoscopy and biopsy is justified. Reference #1 Shovman O, Tamar S, Amital H, Watad A, Shoenfeld Y. Diverse patterns of anti-TNF-α-induced lupus case series and review of the literature. Clin Rheumatol. 2018 Feb;37(2)563-568. Reference #2 Benucci, M., Gobbi, F. L., Fossi, F., Manfredi, M. & Del Rosso, A. (2005). Drug-Induced Lupus After Treatment With Infliximab in Rheumatoid Arthritis. JCR Journal of Clinical Rheumatology, 11 (1), 47-49. Reference #3 Valdés L, San José ME, Pose A, Gude F, González-Barcala FJ, Alvarez-Dobaño JM, Sahn SA. Diagnosing tuberculous pleural effusion using clinical data and pleural fluid analysis A study of patients less than 40 years-old in an area with a high incidence of tuberculosis. Respir Med. 2010 Aug;104(8)1211-7. DISCLOSURES No relevant relationships by Adam Adam No relevant relationships by Moses Bachan No relevant relationships by Chen Chao No relevant relationships by Zinobia Khan No relevant relationships by Milena Vukelic
ADAM protein; adenosine deaminase; chromium; cyclic citrullinated peptide antibody; endogenous compound; histone antibody; infliximab; mesalazine; rheumatoid factor; tumor necrosis factor antibody; unclassified drug; abnormal respiratory sound; adult; ankle; arthralgia; Bacilli; bacterium culture; blood culture; case report; case study; cell culture; clinical article; conference abstract; coronavirus disease 2019; coughing; cytology; diagnosis; diagnostic test accuracy study; drug therapy; drug toxicity; dyspnea; female; fever; gene expression; Gram staining; granulomatosis; human; human cell; hyperpigmentation; hypertension; immunogenicity; incidence; India; kidney; left lung; lupus like syndrome; lymphocyte; mediastinum lymph node; Mycobacterium tuberculosis; non insulin dependent diabetes mellitus; nonhuman; percussion; pleura effusion; pleura fluid; pleurisy; postprimary tuberculosis; predictive value; rheumatoid arthritis; rheumatology; sputum; surgery; swelling; systemic lupus erythematosus; thoracocentesis; thoracoscopy; thorax pain; tuberculosis; tuberculous pleurisy; ulcerative colitis
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EMBASE
Language:
English
Journal:
Chest
Year:
2022
Document Type:
Article
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