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Tuberculosis Developing in a Patient With Long-term High Dose Inhaled Corticosteroid Use: A Case Report FREE TO VIEW

Karen Sobere Yu, DM; Teresita De Guia, DM
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Division of Pulmonary and Critical Care, Philippine Heart Center, Quezon City, Metro Manila, Philippines

Chest. 2014;146(4_MeetingAbstracts):148A. doi:10.1378/chest.1986638
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SESSION TITLE: Infectious Disease Global Case Reports

SESSION TYPE: Global Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Treating patients with substantial doses of oral corticosteroids suppress the immune system, thereby increasing the risk of tuberculosis (TB). However, little is known to its effect on inhaled corticosteroids with risk of tuberculosis.

CASE PRESENTATION: An elderly male aged 72 years old, previous 20 pack-year smoker was diagnosed of TB with bronchiectasis underwent right upper lung lobectomy and embolization. Chest CT scan showed bilateral bronchiectasis with emphysematous changes. He was diagnosed of COPD and compliant on his medications for 5 years now: Salmeterol 50mcg/Fluticasone 500mcg 1 puff BID, Tiotropium and Indacaterol inhalers. Sputum negative for acid fast bacilli last 2012. He came in for fever associated with chills, anorexia, body malaise, and chronic nonproductive cough. He had weight loss of 10% in 1 month. CXR compared from previous showed increasing fibrotic infiltrates both upper lungs, bilateral upper lung cicatricial atelectasis, bilateral perihilar area bronchiectatic/bullous/cavitary changes, discontinuous 5th rib right from post respective surgery. He was admitted for community-acquired pneumonia. However, sputum microscopy showed +2 AFB (1-10 AFB/visual in at least 50 fields). Sputum TB culture and sensitivity test was requested and showed positive for Mycobacterium tuberculosis. Impression was Pulmonary TB, ATS Class 3, Relapse. Isoniazid 300mg, Rifampicin 600mg, Pyrazinamide 1600mg, and Ethambutol 1100mg were started. ICS was withheld during his hospital stay.

DISCUSSION: High dose of inhaled fluticasone (880 ug daily) suppress the proportion of activated circulating T cells among healthy individuals. Prednisolone and inhaled fluticasone are approximately equivalent with 10:1 mg basis in adrenal suppression suggests the possibility of TB reactivation among ICS users. In this respect, there is low incidence of use of inhaled corticosteroid and risk of tuberculosis. In a study at South Korea, only 3.4% incidence rate of inhaled corticosteroid users (>45000 ug cumulative dose, odds ratio >2) was reported to have developed tuberculosis, 67% were men averaged at 67 years old. An analysis of cohort of patients with airway diseases based in Canada also reports an increased risk of TB development among ICS users. Of the patients with airway diseases, COPD and asthma had higher risk. At Philippine Heart Center, this was the only reported case of TB relapse during ICS use. TB relapse refers to a patient who becomes culture-negative while receiving anti-tuberculosis drugs but, at some point after its completion, becomes culture-positive again or experiences clinical/radiographic deterioration consistent with active tuberculosis. In the Philippines, TB prevalence was at 502 per 100,000 population, managed relapse by giving 2 months of Isoniazid/H, Rifampicin/R, Pyrazinamide/Z, Ethambutol/E while awaiting TB culture and sensitivity result obtained prior to initiation of anti-TB medications. Treatment regimen is further individualized based on sensitivity result. If pansusceptible, 2 months of HRZES then 1 month of HRZE, and 5 months of HRE is the treatment regimen. Repeat smears should be done at the end of 3rd, 5th and 8th month of treatment.

CONCLUSIONS: Clinicians should be aware of the possibility of TB reactivation among COPD patients who use high dose corticosteroids. The lowest possible dose of ICS should be taken into consideration whilst regular TB screening is recommended during the ICS use.

Reference #1: Lee, C-H et al. Use of inhaled corticosteroids and the risk of tuberculosis. Thorax. 2013 Dec;68(12):1105-13.

Reference #2: Sharma KC et al. Effects of high-dose inhaled fluticasone propionate via spacer on cell-mediated immunity in healthy volunteers. CHEST 2000; 118:1042-48.

Reference #3: Brassard P et al. Inhaled corticosteroids and risk of tuberculosis in patients with respiratory diseases. Am J Respir Crit Care Med 2011; 183:675-8.

DISCLOSURE: The following authors have nothing to disclose: Karen Sobere Yu, Teresita De Guia

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