Reactivation of Bovine Tuberculosis in Patient Treated with Infliximab, Switzerland

Autor: Andreas W. Jehle, Philip E. Tarr, Juerg Danuser, Claudio Stoebe, Ferdinand Martius, Horst G. Haack, Marina Nager, Reno Frei
Jazyk: angličtina
Rok vydání: 2009
Předmět:
Zdroj: Emerging Infectious Diseases, Vol 15, Iss 7, Pp 1132-1133 (2009)
Emerging Infectious Diseases
ISSN: 1080-6059
1080-6040
Popis: To the Editor: Increased risk for reactivation of tuberculosis (TB) after treatment with tumor necrosis factor (TNF) antagonists, particularly infliximab, is well documented (1). We describe a case of peritoneal TB, probably resulting from reactivation of Mycobacterium bovis infection after infliximab treatment. In retrospect, reactivation might have been preventable had physicians been aware of the patient’s history of regularly drinking fresh cow’s milk from a local farm in Switzerland during 1944–45, when bovine TB was prevalent. The patient was a 69-year-old Swiss woman who was examined for weakness, abdominal pain, increasing abdominal girth, and weight loss in April 2008. Her history included a diagnosis of Crohn disease in 1978 and treatment with glucocorticoids, cyclosporine, and mercaptopurine. In November 2007, during a recurrence of Crohn disease and while receiving treatment with azathioprine, the patient had a negative interferon gamma release assay (IGRA) result (QuantiFERON-TB in Tube test; Cellestis International, Carnegie, Victoria, Australia) and an unremarkable chest radiograph. On November 30, 2007, she was given prednisone (40 mg/d for 2 weeks, then tapered) and prescribed 3 doses of infliximab because of severe inflammation seen during colonoscopy (5 mg/kg on November 30, 2007, January 4, 2008, and February 15, 2008). She was hospitalized on April 25, 2008, at which time she had ascites; the fluid contained 1.4 × 109/L leukocytes (79.5% lymphocytes) but was negative for acid-fast bacilli on direct examination and PCR testing for Mycobacterium tuberculosis complex. Laparoscopy on May 2, 2008, showed extensive peritoneal inflammation. Peritoneal biopsy samples contained acid-fast bacilli and caseating granulomas; PCR for M. tuberculosis complex was positive. At this time, results of a repeat QuantiFERON-TB in Tube test and a tuberculin skin test (TST) were negative, but a T-SPOT.TB (Oxford Immunotec, Abingdon, UK) test was positive (6-kDa early secretory antigenic target [ESAT-6], >20 spots; 10-kDa culture filtrate protein [CFP-10], 11 spots). M. bovis ssp. bovis was grown in cultures of peritoneal biopsy samples. For culture, the MGIT 960 automated culture system (Becton Dickinson, Sparks, MD, USA) was used. The isolate was identified by use of a multiplex PCR-based, solid-phase, reverse-hybridization assay (GenoType MTBC, Hain Lifescience GmbH, Nehren, Germany), excluding M. bovis BCG (2). The patient was discharged May 30, 2008. In January 2009, she was much improved after treatment with isoniazid/rifampin/ethambutol for 3 months and moxifloxacin/rifampin for 5 months. This case of presumed reactivation of peritoneal TB caused by M. bovis in a patient treated with infliximab highlights the need to be aware of local epidemiology with regard to transmissible infectious diseases. It particularly emphasizes the value of careful history taking regarding consumption of unpasteurized dairy products in assessing risk for latent TB infection (LTBI) before starting anti-TNF treatment. Some infectious diseases experts (3) recommend considering LTBI treatment before prescribing anti-TNF therapy even when TST is negative or only minimally positive (
Databáze: OpenAIRE
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