Chest Infections: Fellow Case Report Poster - Chest Infections II |

Anti-TNF Alpha Agent Growing Miliary Seeds FREE TO VIEW

Ronak Shah, MD; Atul Palkar, MBBS; Mangala Narasimhan, DO; Adey Tsegaye, MD
Author and Funding Information

Northwell - North Shore & LIJ, New York, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):125A. doi:10.1016/j.chest.2016.08.134
Text Size: A A A
Published online

SESSION TITLE: Fellow Case Report Poster - Chest Infections II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: This case highlights how miliary tuberculosis can occur in the setting of anti-TNF alpha agent with negative screening Quantiferon and must be considered even when pathology shows non-necrotizing granulomas.

CASE PRESENTATION: A 51-year-old woman with rheumatoid arthritis on Methotrexate, low-dose Prednisone and Adalimumab for the past year, presented with weight loss, generalized fatigue and intermittent low-grade fevers for 2 months. Prior to initiation of Adalimumab therapy the patient tested negative for latent tuberculosis infection with a negative Quantiferon Gold. The chest CT revealed innumerable tiny pulmonary nodules in a miliary pattern. A repeat Quantiferon Gold on admission was positive. She was unable to produce any sputum and underwent a bronchoscopy with bronchoalveolar lavage and transbronchial biopsies. Patient was empirically started on RIPE due to high suspicion for tuberculosis. The AFB cultures after 3 weeks turned positive, growing Mycobacterium tuberculosis. Interestingly, the pathology from the biopsies revealed non-necrotizing granulomas.

DISCUSSION: Miliary TB, roughly accounts for 3% of TB cases, is a clinical disease from hematogenous dissemination, either as a result of progressive primary infection or reactivation of a latent focus. Even though the absence of necrosis on histopathology points to a non-infectious etiology, this is not pathognomonic and does not rule out tuberculosis. The diagnostic evaluation needs to be aggressively tailored to the signs and symptoms, including bronchoscopy with BAL and transbronchial biopsies. TNF-alpha inhibitors greatly increase the risk of reactivation of latent mycobacterial infection. Adalimumab is associated with a much higher rate and presents more frequently in the disseminated form of the mycobacteria compared to the other TNF alpha agents1. The patient tested negative prior to starting Adalimumab, which means that she either had a new infection or more likely, an initial false negative Quantiferon Gold in the setting of chronic immunosuppression and developed reactivation TB. The sensitivities of the Quantiferon Gold can be significantly decreased in immunosuppressed patients to as low as 63%.

CONCLUSIONS: The case illustrates the possibility of false negative screening tests and the potential of miliary tuberculosis with Adalimumab.

Reference #1: Dixon W et al. Drug-specific risk of tuberculosis in patients with RA treated with anti-TNF therapy: results from BSRBR. Ann Rheum Dis. 2010;69:522.

DISCLOSURE: The following authors have nothing to disclose: Ronak Shah, Atul Palkar, Mangala Narasimhan, Adey Tsegaye

No Product/Research Disclosure Information




Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543