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- Title
Tuberculosis-immune reconstitution inflammatory syndrome associated with juvenile enthesitis-related arthritis under treatment of adalimumab.
- Authors
Tani, Yumi; Miyamae, Takako; Hara, Takuma; Yamanaka, Hisashi
- Abstract
The patient, a 13-year-old boy, was diagnosed with juvenile enthesitis-related arthritis at the age of 12. Adalimumab was administered after the arthritis became refractory to methotrexate (MTX) and prednisolone. Before administration of adalimumab, chest X-ray showed no abnormalities, and the results of a T-spot® tuberculosis (TB) test, an IFN-γ release assay for TB infection, were negative. He presented with fever and cough after 2 months of adalimumab treatment. Chest CT showed a nodular lesion in the right upper lung lobe and a miliary shadow in both lung fields. He was diagnosed with lung and miliary TB by Mycobacterium tuberculosis based on positive findings on a repeat T-spot® TB test, an acid-fast bacilli (AFB) smear of gastric secretion (Gaffky 1), and PCR. Adalimumab and MTX were discontinued, and standard anti-TB treatment was initiated. A drug sensitivity test showed sensitivity to four anti-TB drugs, and his manifestations gradually subsided. Five months later, he presented with cough with bloody sputum, and chest CT revealed further enlargement of the right hilar and subclavian lymph nodes with right upper lobe atelectasis. Sputum AFB was graded Gaffky 9, whereas a mycobacterium culture was negative. He was diagnosed with TB-immune reconstitution inflammatory syndrome (IRIS) and his manifestations and imaging findings showed gradual improvement without any additional treatment. This is the first reported pediatric case of miliary TB that developed during adalimumab treatment and was complicated by TB-IRIS. No recommendations for treatment of juvenile idiopathic arthritis patients with TB exists in Japan; however, additional immunosuppressive therapy to suppress immune responses against M. tuberculosis may be important for patients with severe TB-IRIS.
- Subjects
TUBERCULOSIS case studies; IMMUNE reconstitution inflammatory syndrome; ADALIMUMAB; JUVENILE idiopathic arthritis; TUMOR necrosis factors
- Publication
Modern Rheumatology Case Reports, 2018, Vol 2, Issue 2, p149
- ISSN
2472-5625
- Publication type
Case Study
- DOI
10.1080/24725625.2018.1432969