Miliary tuberculosis presenting as tenosynovitis in a case of rheumatoid arthritis

Tuberculosis of the wrist causing carpal tunnel syndrome in a patient with rheumatoid arthritis: A case report

Among extrapulmonary tuberculosis, osteoarticular tuberculosis is a rare manifestation, and cases related to osteoarticular tuberculosis of large joints have been reported previously. However, tuberculous tenosynovitis causing carpal tunnel syndrome is a rare manifestation, especially in the background of rheumatoid arthritis. A 67-year-old Sri Lankan male with a background of rheumatoid arthritis presented with progressively enlarging left wrist swelling associated with pain and numbness for 2 months. He was on Methotrexate and Hydroxychloroquine as disease-modifying agents, and his symptoms related to arthritis were well controlled. On examination, lobulated subcutaneous swelling was noted in distal forearm extending to the palmar region with evidence of carpal tunnel syndrome which was confirmed by nerve conduction studies. There was no pre-operative evidence to suggest tuberculosis both clinically and biochemically. Synovial thickening due to rheumatoid arthritis was considered as the probable diagnosis and surgical decompression of the carpal tunnel was performed. Intraoperatively, synovial thickening was noted around the flexor tendons with evidence of median nerve compression in the carpal tunnel. Thickened synovial mass was completely excised. Histology and culture were positive for tuberculosis. Following excision and 9 months of anti-tuberculosis treatment, he was asymptomatic with good range of motion of fingers. In conclusion, a combination of surgical excision and anti-tuberculosis treatment was successful to achieve good functional outcomes. In a country like Sri Lanka, where tuberculosis is still prevalent, uncommon musculoskeletal manifestations may not be infrequent. Therefore, clinicians should have a high degree of suspicion when treating such patients.

Risk of tuberculosis reactivation associated with traditional disease modifying anti-rheumatic drugs and non-anti-tumor necrosis factor biologics in patients with rheumatic disorders and suggestion for clinical practice

INTRODUCTION

Two classes of biologics, anti-tumor necrosis factor (TNF) and non-anti-TNF targeted, are currently available for the treatment of rheumatic diseases.

AREAS COVERED

Discussion on the need for LTBI diagnosis in rheumatic patients treated csDMARDs and non-anti-TNFs through a review of the literature. The literature, updated to 15 April 2019, on tuberculosis (TB) reactivation risk in patients exposed to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and non-anti-TNF biologics was reviewed.

EXPERT OPINION

An increased risk of TB reactivation in patients receiving csDMARDs (except sulphasalazine) resulted, while a review of clinical trials, and Periodic Safety Update Reports from pharmaceutical Companies evidenced a very low or absent risk for non-anti-TNF biologics. Hence, a contradiction emerges considering that latent TB infection (LTBI) screening is recommended for non-anti-TNF candidates but not for csDMARDs. Concerning the low TB incidence countries, several actions could be undertaken, including to screen all patients independently on the treatment, to omit the procedure in non-anti-TNF candidates, or to perform the LTBI investigations only in high-risk patients. According to WHO guidelines, LTBI screening in low TB risk countries seems unnecessary, except in high TB risk subjects.

Tuberculosis infection in patients with rheumatoid arthritis and the effect of infliximab therapy

OBJECTIVE

According to the Centers for Disease Control and Prevention, the 1999 and 2000 incidence rates for tuberculosis (TB) in the US population were 6.4 and 5.8, respectively, per 100,000 persons. Recently, reports of TB following infliximab administration have raised questions regarding the rate of TB in patients with rheumatoid arthritis (RA) generally and in those treated with infliximab in clinical practice. We undertook this study to determine the baseline rate of TB in RA prior to the introduction of infliximab and to determine the rate of TB among those currently receiving infliximab.

METHODS

We surveyed patients with questionnaires, followed by detailed validation from medical records and physician reports. In study 1, we evaluated 10,782 RA patients in 1998-1999 prior to the widespread use of infliximab. In study 2, we evaluated 6,460 infliximab-treated patients in 2000-2002.

RESULTS

In study 1, the lifetime rate of TB was 696 per 100,000 patients (95% confidence interval [95% CI] 547-872). Of these cases, 76.8% occurred prior to the onset of RA. During the period of prospective followup, 1 case of TB developed during 16,173 patient-years of followup, yielding a rate of 6.2 cases (95% CI 1.6-34.4) per 100,000 patients. In study 2, the TB incidence rate among infliximab-treated patients was 52.5 cases (95% CI 14.3-134.4) per 100,000 patient-years of exposure. Three of the 4 cases occurred in patients with a history of TB exposure, and no cases occurred in persons with recent TB skin tests or prophylaxis.

CONCLUSION

The rate of TB is not increased in RA patients generally. Among infliximab-treated patients, the rate is 52.5 cases (95% CI 14.3-134.4) per 100,000 patient-years of exposure. A thorough medical history regarding TB, as well as tuberculin testing and radiographic examination (if indicated), should be an essential component of anti-tumor necrosis factor therapy.

Infections in the immunocompromised rheumatologic patient

Immunocompromised patients with rheumatic diseases have an increased risk of infections. A major risk factor for infection seems to be the immunosuppressive therapy used. Newer therapies for RA may lead to increased rates of infection by opportunistic pathogens such as Mycobacteria tuberculosis. Because disease manifestation may mimic signs and symptoms of infection, prompt diagnosis may be difficult. Familiarity with the likely infections and their causes should aid in obtaining the appropriate culture specimens.

Infections in systemic lupus erythematosus and rheumatoid arthritis

Patients with systemic lupus erythematosus have a higher infection rate than the general population. It is estimated that at least 50% of them will suffer a severe infectious episode during the course of the disease. Improvements in the control of the disease are discussed in this article.

Mycobacterium intracellulare as a cause of a recurrent granulomatous tenosynovitis of the hand

We report a case of recurrent granulomatous tenosynovitis with M. intracellulare in a 55-year-old HIV negative diabetic woman. Identification of the causative agent further than belonging to the M. avium-intracellulare complex is provided by specific PCR-amplification of genomic DNA and sequencing of an hypervariable region within its 16S RNA gene. Sixteen months antibiotic regimen of rifabutin and clarithromycin led to a complete resolution of the tenosynovitis.