Korean J Gastroenterol.  2019 Sep;74(3):168-174. 10.4166/kjg.2019.74.3.168.

Multidrug-resistant Disseminated Tuberculosis Related to Infliximab in a Patient with Ulcerative Colitis and Negative Evaluation for Latent Tuberculosis

• Jun YK
• Chun J
• Kang EA
• Lee HJ
• Im JP
• Kim JS

• KMID: 2458698
• DOI: http://doi.org/10.4166/kjg.2019.74.3.168

Abstract

Anti-tumor necrosis factor (anti-TNF) is an effective biological agent for the treatment of moderate-to-severe active ulcerative colitis (UC) refractory to conventional therapy. On the other hand, anti-TNF therapy is strongly associated with a potential risk of tuberculosis (TB). Active TB is a critical complication that makes it difficult to treat patients who require anti-TNF for the treatment of UC refractory to conventional therapy. Based on the clinical guidelines, patients with inflammatory bowel disease (IBD) are strongly recommended to screen for latent TB before anti-TNF administration. Considering the possibility of active or reactivated TB related to anti-TNF therapy, all patients with IBD should be monitored closely for TB during anti-TNF therapy, irrespective of the screening results for latent TB. In particular, the risk of anti-TNF-related multidrug-resistant TB (MDR-TB) in patients with IBD has not been elucidated. This paper reports the first case of disseminated MDR-TB that developed in a UC patient receiving infliximab despite the negative evaluation for latent TB screening.

Keyword

Inflammatory bowel diseases; Infliximab; Tuberculosis, multidrug-resistant; Colitis, ulcerative

MeSH Terms

Colitis, Ulcerative*
Hand
Humans
Inflammatory Bowel Diseases
Infliximab*
Latent Tuberculosis*
Mass Screening
Necrosis
Tuberculosis*
Tuberculosis, Multidrug-Resistant
Ulcer*
Infliximab

Figure

• 

  Fig. 1 Colonoscopy exams showed (A, B) mild erythema, edema, and exudate with inflammatory pseudopolyps were noted from the cecum to the ascending colon, and (C, D) multiple whitish scars were found from the sigmoid colon to the rectum.

• 

  Fig. 2 Computed tomography of the chest, abdomen and pelvis showed (A) a large volume of ascites with diffuse peritoneal thickening (arrows), which are consistent with tuberculous peritonitis, and (B) enlarged lymph nodes in the right upper and lower paratracheal area (arrows).

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  Fig. 3 Acid-fast bacilli (AFB) stain of a paratracheal lymph node biopsy specimen showed granulomatous inflammation with multinucleated giant cells. AFB were not detected in the specimen (AFB, ×400).

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  Fig. 4 Clinical course. She experienced disseminated multidrug-resistant tuberculosis involved in the lung, peritoneal cavity, and multiple lymph nodes 27 weeks after the initiation of infliximab for the treatment of ulcerative colitis, despite the negative results for latent tuberculosis screening. UC, ulcerative colitis; MDR-TB, multidrug-resistant tuberculosis; W, week; Km, Kanamycin; Lfx, levofloxacin; Pto, prothionamide; Cs, cycloserine; Lzd, linezolid.

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