Letter to the Editor
Miliary tuberculosis in a rheumatoid arthritis patient receiving long-term tumor necrosis factor monoclonal antibody therapy
C.-R. Wanga,
, W.-C. Lina, Y.-S. Tsaib
Corresponding author
wangcr@mail.ncku.edu.tw
Corresponding author at: Department of Internal Medicine, National Cheng Kung University Hospital, 138 Sheng-Li Road, Tainan 70403, Taiwan.
Corresponding author at: Department of Internal Medicine, National Cheng Kung University Hospital, 138 Sheng-Li Road, Tainan 70403, Taiwan.
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"apellidos" => "Wang" "email" => array:1 [ 0 => "wangcr@mail.ncku.edu.tw" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "W.-C." "apellidos" => "Lin" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Y.-S." "apellidos" => "Tsai" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Medical Imaging, National Cheng Kung University Hospital, Tainan, Taiwan" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author at: Department of Internal Medicine, National Cheng Kung University Hospital, 138 Sheng-Li Road, Tainan 70403, Taiwan." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3204 "Ancho" => 3167 "Tamanyo" => 585324 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical images of miliary TB in a RA patient receiving TNF mAb therapy. (A). A clear chest X-ray without any lung lesions before starting TNF mAb therapy. (B). Bilateral diffuse military lesions on chest X-ray after TNF mAb therapy. (C). Bilateral innumerable micronodular opacities on chest computed tomography after TNF mAb therapy. (D). Resolved bilateral military nodules on chest computed tomography after anti-TB treatment.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 51-year-old woman had a diagnosis of seropositive rheumatoid arthritis (RA) with polyarthritis involving bilateral elbow, small joints of hand and knee areas on March 12, 2004. Owing to refractory therapeutic responses with a DAS28 score of 6.16 under methotrexate 15<span class="elsevierStyleHsp" style=""></span>mg/week, hydroxychloroquine 400<span class="elsevierStyleHsp" style=""></span>mg/day and prednisolone 10<span class="elsevierStyleHsp" style=""></span>mg/day, she started to receive regular biweekly 40<span class="elsevierStyleHsp" style=""></span>mg subcutaneous injection of adalimumab, a tumor necrosis factor (TNF) monoclonal antibody (mAb) since June 17, 2011. She had no history of lung diseases with a clear chest X-ray (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). There was a negative QuantiFERON test before initiating anti-TNF<span class="elsevierStyleHsp" style=""></span>therapy. She had reduced disease activity after treatment without further prescription of hydroxychloroquine and prednisolone. Owing to productive cough with intermittent fever and weight loss for 3 weeks, the use of TNF mAb was discontinued on February 20, 2018, 80 months after initiating such a treatment. However, she did not receive follow-up QuantiFERON test during her long-term anti-TNF therapy. Chest images including X-ray (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B) and computed tomography (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C) showed bilateral diffuse miliary lesions characterized by innumerable micronodular opacities. She had no exposure to fine mineral or chemical dust, and her malignancy survey and human immunodeficiency virus examination were negative results. Sputum cultures were positive for <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span>. There was no recent household tuberculosis (TB) contact history. She received anti-TB medications with daily dosages of rifampicin 480<span class="elsevierStyleHsp" style=""></span>mg, isoniazid 320<span class="elsevierStyleHsp" style=""></span>mg, pyrazinamide 1000<span class="elsevierStyleHsp" style=""></span>mg and ethambutol 800<span class="elsevierStyleHsp" style=""></span>mg for 9 months from April 12, 2018 (drug-susceptibility testing in TB with resistance to streptomycin and sensitive to others). After antibiotic therapy, there were no more respiratory or constitutional symptoms, negative sputum culture results and resolved pulmonary miliary nodules (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> D). For her arthritis flare-up after discontinuing TNF mAb injection, rituximab, a B-cell depleting mAb, under a regimen of 1<span class="elsevierStyleHsp" style=""></span>g<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>two fortnightly infusions every 6 months was initiated on February 7, 2020 with improved disease activity (DAS 28 score 5.34 to 2.70) after 4 infusions at the end of 2020.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Miliary TB, a rare fatal presentation of mycobacterial infection, can occur in the presence of impaired host immunity under the prescription of immunosuppressive agents.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> TNF blocker administration has been recognized as a risk for TB reactivation in various autoimmune-mediated inflammatory disorders,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> especially when anti-TNF treatment is combined with the use of immunosuppressive agents like methotrexate.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Greater incidences are found during the first year of treatment than afterwards, while there are higher occurrences with mAb than with recombinant soluble receptor fusion protein therapy. Despite an additional risk of having been born in an area of endemic TB,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> the reported case raises a potential infection hazard under the long-term TNF mAb treatment.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In conclusion, we reported miliary TB in a RA patient receiving long-period TNF blocker therapy. In addition to the initial QuantiFERON survey, periodic latent TB testing should be carried out in patients receiving the long-term immunosuppressive agents like TNF monoclonal antibodies.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Author contributions</span><p id="par0020" class="elsevierStylePara elsevierViewall">Study conception and design: Chrong-Reen Wang.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Data analysis and acquisition: Chrong-Reen Wang, Wei-Chieh Lin, Yi-Shan Tsai.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Drafting of the manuscript: Chrong-Reen Wang.</p><p id="par0035" class="elsevierStylePara elsevierViewall">All authors had access to the data and played a role in writing this manuscript.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Author contributions" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:2 [ "identificador" => "xack543242" "titulo" => "Acknowledgments" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3204 "Ancho" => 3167 "Tamanyo" => 585324 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical images of miliary TB in a RA patient receiving TNF mAb therapy. (A). A clear chest X-ray without any lung lesions before starting TNF mAb therapy. (B). Bilateral diffuse military lesions on chest X-ray after TNF mAb therapy. (C). Bilateral innumerable micronodular opacities on chest computed tomography after TNF mAb therapy. (D). Resolved bilateral military nodules on chest computed tomography after anti-TB treatment.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Miliary tuberculosis: new insights into an old disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S.K. Sharma" 1 => "A. Mohan" 2 => "A. Sharma" 3 => "D.K. Mitra" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S1473-3099(05)70163-8" "Revista" => array:6 [ "tituloSerie" => "Lancet Infect Dis" "fecha" => "2005" "volumen" => "5" "paginaInicial" => "415" "paginaFinal" => "430" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15978528" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Severe rifampicin-induced thrombocytopenia in a patient with miliary tuberculosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Maurício" 1 => "B. Flor-de-Lima" 2 => "P. Pacheco" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.pulmoe.2019.09.005" "Revista" => array:6 [ "tituloSerie" => "Pulmonology" "fecha" => "2020" "volumen" => "26" "paginaInicial" => "247" "paginaFinal" => "249" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31722846" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risk of tuberculosis is higher with anti-tumor necrosis factor monoclonal antibody therapy than with soluble tumor necrosis factor receptor therapy: the three-year prospective French Research Axed on Tolerance of Biotherapies registry" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F. Tubach" 1 => "D. Salmon" 2 => "P. Ravaud" 3 => "Y. Allanore" 4 => "P. Goupille" 5 => "M. 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Gatta" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3109/07853890.2014.941919" "Revista" => array:6 [ "tituloSerie" => "Ann Med" "fecha" => "2014" "volumen" => "46" "paginaInicial" => "547" "paginaFinal" => "554" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25105206" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mycobacterium tuberculosis in Taiwan" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "P.R. Hsueh" 1 => "Y.C. Liu" 2 => "J. So" 3 => "Y.C. Liu" 4 => "P.C. Yang" 5 => "K.T. 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