A case of paradoxical response during anti-tuberculosis treatment in a patient with ulcerative colitis.

Emerging anti-tumor necrosis factor (TNF)-α antibodies therapy changed treatment strategy to inflammatory bowel diseases because of the efficacy. However, TNF-α inhibitor can be associated with an increased risk of infectious complications, especially tuberculosis. A 71-year-old female with steroid-dependent ulcerative colitis (UC) was admitted due to relapse of UC with endoscopically severe active. Golimumab and adjunctive prednisolone started with 30 mg daily resulted in clinical remission. However, she had general fatigue and fever at the time of seventh injection of golimumab without abdominal symptoms. Based on positive interferon-gamma release assay, polymerase chain reaction positive for tuberculosis (TB) in pleural fluid, and chest computed tomography, she was diagnosed as tuberculous pleuritis. Standard anti-TB treatment (isoniazid, rifampicin, ethambutol, and pyrazinamide) was started without cessation of golimumab, because cessation of TNF-α inhibitors during anti-TB treatment could cause the paradoxical response by skewing from regulatory to inflammatory immune responses. However, four weeks after initiation of anti-TB treatment, she got fever-up and pleural effusion increased. We then started prednisolone 30 mg daily as diagnosis of paradoxical response, resulting in improving the symptoms. This is a suggestive case of paradoxical response during anti-TB treatment despite continuous TNF-α inhibitors.

Multiple organ tuberculosis of lung, pleura, and peritoneum in ankylosing spondylitis during adalimumab therapy.

A case of multiple organ tuberculosis (TBc) involving lung, pleura, and peritoneum in a 39-year-old man with long-standing ankylosing spondylitis (AS) treated with adalimumab was presented. The relationship between antitumor necrosis factor-α (anti-TNF-α) therapy and TBc was also reviewed. This case illustrates that TBc can develop in multiple organs during adalimumab therapy, and thus, the awareness of serious complications of multiple organs and atypical extrapulmonary pattern of TBc during anti-TNF-α therapy needs to be increased.

[A case of pulmonary tuberculosis and tuberculous pleuritis during treatment with etanercept for rheumatoid arthritis].

A 64-year-old woman, afflicted with rheumatoid arthritis, consulted our hospital because of her clinical deterioration. Her doctor started treating her with etanercept and prednisolone 10 mg/day but without preventive chemotherapy for tuberculosis, because her chest CT showed only mild interstitial pneumonia, and her tuberculin test showed a slightly-positive reaction. Her symptoms improved, but her chest X-ray showed infiltration after two and a half months treatment, and right pleural effusion after four and a half months treatment. A diagnosis of pulmonary tuberculosis and tuberculous pleuritis was made because of an increase of adenosine deaminase in pleural effusion. She was treated with isoniazid, rifampicin, and ethambutol, resulting in a successful clinical course. Her sputum culture was positive, and a nucleic-acid amplification of Mycobacterium tuberculosis complex was positive. When prescribing etanercept, we should pay close attention to the possibility of tuberculosis.

[Tuberculous pleurisy after tumour necrosis factor-alpha antagonist usage: case report]. / Tümör nekroz faktörü-alpha antagonisti kullanimi sonrasi gelisen tüberküloz plörezi: Olgu sunumu.

A thirty-six year old male patient presented with dyspnea, right-sided chest pain, night sweats and intermittent fever. He has a history of ankylosing spondylitis treated with tumour necrosis factor-alpha (TNF-alpha) antagonist (infliximab). Computed tomography of the chest showed mediastinal lymphadenopathy, right-sided pleural effusion, and atelectasis. The pleural fluid was exudative with lymphocyte dominance. Closed pleural biopsy was nondiagnostic. The adenosine deaminase level of the pleural fluid was 110 U/L. In light of these findings, the patient was diagnosed as tuberculous pleurisy and antituberculous treatment was given. After one month, pleural fluid was markedly reduced.

Rapid immunodiagnosis of tuberculosis in a woman receiving anti-TNF therapy.

BACKGROUND: A 63-year-old German woman with a 24-year history of Crohn's disease and associated polyarthralgias presented with severe malaise, dyspnea, fever, night sweats, dry cough and an extensive right-sided pleural effusion. The patient had begun treatment with bi-weekly subcutaneous injections of adalimumab 5 weeks earlier. INVESTIGATIONS: Physical examination, chest X-ray, transthoracic ultrasonography, pleural tap and drainage, bacterial and cytological analyses of pleural fluid, bronchoscopy, microscopy and bacteriological culture of pleural exudates and bronchoalveolar lavage fluid, thoracic CT, thoracoscopy, histopathology of pleural biopsy, tuberculin skin test, nucleic acid amplification of mycobacterial RNA and DNA in the pleural fluid specimens and the parietal pleural biopsy, microscopy of sputum samples, ESAT-6-specific and CFP-10-specific interferon-gamma enzyme-linked immunospot assay on peripheral blood and pleural exudate mononuclear cells. DIAGNOSIS: Pulmonary and pleural tuberculosis. MANAGEMENT: Cessation of adalimumab treatment. Initiation of quadruple antibiotic therapy with isoniazid, rifampin, ethambutol and pyrazinamide. Prednisolone administered to reduce the pleural effusion.

[Two cases of respiratory infection complicating treatment with infliximab].

Infliximab, an anti-TNF-alpha agent, is highly effective against rheumatoid arthritis and Crohn's disease. However, respiratory infection can occur as a complication. We report two cases complicated by respiratory infection following administration of infliximab. The first case, a 67-year-old woman with rheumatoid arthritis, developed pneumocystis pneumonia after three courses of infliximab therapy. The second case, a 31-year-old man with Crohn's disease, developed pulmonary tuberculosis after four courses of infliximab therapy. Respiratory complications associated with anti-TNF therapy include infectious diseases such as pneumocystis pneumonia, tuberculosis, and bacterial pneumonia. They often lead a fulminant course, and early diagnosis is essential. The final report of a survey of the initial 5000 cases with rheumatoid arthritis treated with infliximab in Japan was released in April 2006; pulmonary infectious complications included 22 cases of pneumocystis pneumonia, 14 cases of tuberculosis, and 108 cases of bacterial pneumonia. The growing use of anti-TNF therapy might lead to increasing pulmonary complications. Accumulation of similar cases is expected to elucidate the mechanism of the complications and methods for effective prophylaxis.