Ulcerative intestinal tuberculosis case as a complication of treatment by infliximab for intestinal Behçet's disease: A case report

The Long-Term Journey of a Tuberculosis Patient With Triple Organ Involvement and Rheumatological Disease: A Case Study and Literature Review

Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis bacteria, which is more prevalent among immunocompromised individuals. According to the distribution of affected organs, this infection can be categorized as either pulmonary or extrapulmonary TB. Immunodeficiency states resulting from rheumatological disorders and the use of immunosuppressive medications, such as in Behçet's disease (BD), are potential predisposing factors for TB, particularly in cases involving multiple organs. These situations can introduce challenges in both the diagnosis and treatment of patients. We describe a 43-year-old man with a history of BD who presented with symptoms of weight loss, abdominal pain, and shortness of breath. His chest X-ray revealed cavities and calcifications, while an abdominal X-ray demonstrated signs of intestinal obstruction and adhesions. Subsequent TB diagnosis led to a 6-month course of a TB treatment regimen. Despite treatment initiation, the patient developed a brain abscess 1 year later, necessitating surgical intervention. Following the procedure, he received another 1-year course of a TB treatment regimen and experienced full recovery without any complications during a 2-year follow-up period. Notably, the patient recently received a Sinopharm COVID-19 vaccine and subsequently developed seizures that are currently being managed with anticonvulsant therapy. This case report emphasizes the significance of including pulmonary TB in complex medical cases, especially in individuals with autoimmune diseases. Early diagnosis and treatment are crucial for improving outcomes and reducing the risk of complications. Furthermore, it highlights the possible correlation between TB and BD, along with the potential adverse reactions to COVID-19 vaccines in this population, which necessitate special consideration by healthcare professionals.

(Re-)introduction of TNF antagonists and JAK inhibitors in patients with previous tuberculosis: a systematic review

BACKGROUND

Tuberculosis (TB) is a common complication associated with treatment with tumour necrosis factor (TNF) antagonists and Janus kinase (JAK) inhibitors. However, there is uncertainty about the risk of TB relapse in patients with TB and comorbidities requiring treatment with these agents.

OBJECTIVES

To assess the risk of TB relapse in patients (re-)started on TNF antagonists or JAK inhibitors.

METHODS

Systematic review.

DATA SOURCES

PubMed and Cochrane Library databases until 11 December 2023.

STUDY ELIGIBILITY CRITERIA

Randomized control trials, prospective and retrospective cohort studies, case reports and case series.

PARTICIPANTS

Patients with current or previous TB who were (re-)started on TNF antagonists or JAK inhibitors.

INTERVENTIONS

(Re-)introduction of TNF antagonists and JAK inhibitors.

ASSESSMENT OF RISK OF BIAS

All studies meeting entry criteria were included regardless of quality.

METHODS OF DATA SYNTHESIS

Categorical data are presented as frequencies and percentages. For non-normally distributed aggregated data, we calculated the pooled weighted median with 95% CI. For individual patient data, the median and interquartile range (IQR) were calculated.

RESULTS

Of 5018 articles screened for eligibility, 67 publications reporting on 368 TB patients who (re-)initiated treatment with TNF antagonists for underlying diseases were included. The median age was 42.5 years (95% CI: 40.4-42.5) and the proportion of female patients was 36.6% (n = 74) of patients whose sex was reported. A total of 14 patients (3.8%, 95% CI: 2.1-6.3%) developed TB relapse after a median of 8.5 months (interquartile range, 6.8-14.8 months) following (re-)initiation of anti-TNF treatment. Furthermore, among 251 articles screened for eligibility, 11 reports on TB patients who were (re-)started on JAK inhibitors for underlying diseases were identified. The median age was 62 years (interquartile range, 48.5-68.5 years) and 45.5% (n = 5) were female. Only one patient (9.1%; 95% CI: 0.2-41.3%) had TB reactivation 10 months after starting treatment with ruxolitinib. In addition, 94 patients who were treated with TNF antagonists and two patients temporarily treated with JAK inhibitors for the prevention or treatment of paradoxical reactions were analysed. None of the publications reported microbiological failure or worsening of TB-related symptoms.

CONCLUSIONS

(Re-)initiation of TNF antagonists and JAK inhibitors may be relatively safe in patients with current or previous TB and the need for further treatment of underlying diseases.