Download PDF
Z Gastroenterol 2013; 51(10): 1177-1183
DOI: 10.1055/s-0033-1350372
Kasuistik
© Georg Thieme Verlag KG Stuttgart · New York

Development of Miliary Tuberculosis under Infliximab in a Patient with Spondyloarthritis and Suspected Crohn’s Disease

Entwicklung einer Miliartuberkulose unter Infliximab in einem Patienten mit Spondyloarthritis und vermutetem Morbus Crohn
R. Koschny
1   Dept. of Gastroenterology, Heidelberg University Hospital, Heidelberg
,
T. Junghanss
2   Section Clinical Tropical Medicine, Dept. of Infectious Diseases, Heidelberg University Hospital, Heidelberg
,
A. Mischnik
2   Section Clinical Tropical Medicine, Dept. of Infectious Diseases, Heidelberg University Hospital, Heidelberg
,
M. Karner
3   Dept. of Gastroenterology, St. Josefs Hospital, Viernheim
,
M. Kreuter
4   Pneumology and respiratory critical care medicine, Thoraxklinik, University of Heidelberg and German Center for Lung Research (DZL), Heidelberg (TLRC-H), Heidelberg University Hospital, Heidelberg
,
W. Roth
5   Institute of Pathology, Heidelberg University Hospital, Heidelberg
,
W. Stremmel
1   Dept. of Gastroenterology, Heidelberg University Hospital, Heidelberg
,
U. Merle
1   Dept. of Gastroenterology, Heidelberg University Hospital, Heidelberg
› Author Affiliations
Further Information

Publication History

20 June 2013

12 July 2013

Publication Date:
11 October 2013 (online)

Also available at
    Permissions and Reprints

Abstract

Tuberculosis (TB) infection is a major concern in patients with chronic autoimmune conditions under immunosuppressive therapy. Gastrointestinal tuberculosis can be misdiagnosed as Crohn’s disease with detrimental consequences for the patient. We report on a 40-year old ethnic Turkish patient with HLA-B27 positive spondyloarthritis who developed gastrointestinal symptoms under immunosuppressive treatment with infliximab. Crohn’s disease was diagnosed at a primary care hospital and immunosuppressive treatment was escalated. Initial diagnostic tests for tuberculosis were negative. When the clinical condition deteriorated, the patient was transferred to our intensive care unit for further diagnosis and treatment. Tuberculosis was suspected due to clinical presentation and radiological signs and anti-tuberculous treatment was initiated. After the onset of treatment, first microbiological results confirmed the diagnosis of miliary TB with Mycobacterium bovis. As an infection route we assume primary gastrointestinal infection with M. bovis during the patient’s annual holidays in Turkey with a rapid development of miliary TB under infliximab and escalated immunosuppressive therapy. This case report demonstrates the difficulties in differentiating intestinal TB from other granulomatous conditions such as Crohn’s disease. The diagnostic tools for gastrointestinal tuberculosis are discussed in detail regarding their sensitivity, specificity as well as positive and negative predictive values.

Zusammenfassung

Die immunsuppressive Therapie bei Patienten mit einer Autoimmunerkrankung stellt ein Risiko für die Entwicklung einer Tuberkulose (Tbc) dar. Zudem kann eine gastrointestinale Tuberkulose leicht als Morbus Crohn fehldiagnostiziert werden. Wir berichten von einem 40-jährigen türkisch-stämmigen Patienten mit einer HLA-B27 positiven Spondylarthritis, der unter einer Immunsuppression mit Infliximab gastrointestinale Beschwerden entwickelte. In einem auswärtigen Krankenhaus wurde die Diagnose eines Morbus Crohn gestellt und die Immunsuppression eskaliert. Die initial durchgeführte Tbc-Diagnostik war negativ. Aufgrund einer Verschlechterung des klinischen Zustands wurde der Patient zur weiteren Abklärung und Therapie auf unsere Intensivstation verlegt. Bei klinischem und radiologischem Verdacht auf eine Tuberkulose wurde unverzüglich eine Vierfachtherapie eingeleitet. Nach Beginn der spezifischen Therapie bestätigten die mikrobiologischen Befunde eine pulmonale und intestinale Tbc durch Mycobacterium bovis. Als Infektionsquelle vermuten wir eine primäre gastrointestinale Infektion mit M. bovis, welche der Patient während seines jährlichen Türkeiurlaubs erworben haben könnte. Unter der eskalierten Immunsuppression und anti-TNF-Therapie mit Infliximab entwickelte sich eine frühe Generalisierung mit Ausbildung einer Miliartuberkulose. Unser Fallbericht veranschaulicht die differenzialdiagnostischen Schwierigkeiten bei der Unterscheidung einer intestinalen Tbc von anderen granulomatösen Erkrankungen, wie einem M. Crohn. Die Diagnostik einer gastrointestinalen Tbc wird hinsichtlich ihrer Sensitivität, Spezifität und den negativen sowie positiven prädiktiven Werten ausführlich diskutiert.

Key words

infectious colitis - Crohn’s disease - lower GI bleeding - immunosuppression - anti-TNF-treatment - gastrointestinal tuberculosis - miliary tuberculosis

Schlüsselwörter

infektiöse Kolitis - Morbus Crohn - untere gastrointestinale Blutung - Immunsuppression - anti-TNF-Therapie - gastrointestinale Tuberkulose - Miliartuberkulose
 

  • References

  • 1 Zumla A, Raviglione M, Hafner R et al. Tuberculosis. N Engl J Med 2013; 368: 745-755
    CrossrefPubMedGoogle Scholar
  • 2 Almadi MA, Ghosh S, Aljebreen AM. Differentiating intestinal tuberculosis from Crohn’s disease: a diagnostic challenge. Am J Gastroenterol 2009; 104: 1003-1012
    CrossrefPubMedGoogle Scholar
  • 3 Barouni AS, Augusto CJ, Lopes MT et al. A pncA polymorphism to differentiate between Mycobacterium bovis and Mycobacterium tuberculosis. Mol Cell Probes 2004; 18: 167-170
    CrossrefPubMedGoogle Scholar
  • 4 Fitzgerald SD, Schooley AM, Berry DE et al. Antimicrobial susceptibility testing of Mycobacterium bovis isolates from Michigan white-tailed deer during the 2009 hunting season. Vet Med Int 2010; 2011: 903683
    PubMedGoogle Scholar
  • 5 Schaberg T, Bauer T, Castell S et al. [Recommendations for therapy, chemoprevention and chemoprophylaxis of tuberculosis in adults and children. German Central Committee against Tuberculosis (DZK), German Respiratory Society (DGP)]. Pneumologie 2012; 66: 133-171
    Article in Thieme ConnectPubMedGoogle Scholar
  • 6 Geng E, Kreiswirth B, Burzynski J et al. Clinical and radiographic correlates of primary and reactivation tuberculosis: a molecular epidemiology study. JAMA 2005; 293: 2740-2745
    CrossrefPubMedGoogle Scholar
  • 7 Steingart KR, Ng V, Henry M et al. Sputum processing methods to improve the sensitivity of smear microscopy for tuberculosis: a systematic review. Lancet Infect Dis 2006; 6: 664-674
    CrossrefPubMedGoogle Scholar
  • 8 Gonzalez-Angulo Y, Wiysonge CS, Geldenhuys H et al. Sputum induction for the diagnosis of pulmonary tuberculosis: a systematic review and meta-analysis. Eur J Clin Microbiol Infect Dis 2012; 31: 1619-1630
    CrossrefPubMedGoogle Scholar
  • 9 Chawla R, Pant K, Jaggi OP et al. Fibreoptic bronchoscopy in smear-negative pulmonary tuberculosis. Eur Respir J 1988; 1: 804-806
    PubMedGoogle Scholar
  • 10 Shin JA, Chang YS, Kim TH et al. Fiberoptic bronchoscopy for the rapid diagnosis of smear-negative pulmonary tuberculosis. BMC Infect Dis 2012; 12: 141
    CrossrefPubMedGoogle Scholar
  • 11 Diagnostic Standards and Classification of Tuberculosis in Adults and Children. This official statement of the American Thoracic Society and the Centers for Disease Control and Prevention was adopted by the ATS Board of Directors, July 1999. This statement was endorsed by the Council of the Infectious Disease Society of America, September 1999. Am J Respir Crit Care Med 2000; 161: 1376-1395
    CrossrefPubMedGoogle Scholar
  • 12 Bloemberg GV, Voit A, Ritter C et al. Evaluation of COBAS(R) TaqMan MTB for direct detection of Mycobacterium tuberculosis complex in comparison with the COBAS(R) Amplicor MTB. J Clin Microbiol 2013; 51: 2112-2117
    CrossrefPubMedGoogle Scholar
  • 13 Lawn SD, Zumla AI. Tuberculosis. Lancet 2011; 378: 57-72
    CrossrefPubMedGoogle Scholar
  • 14 Laifer G, Widmer AF, Frei R et al. Polymerase chain reaction for Mycobacterium tuberculosis: impact on clinical management of refugees with pulmonary infiltrates. Chest 2004; 125: 981-986
    CrossrefPubMedGoogle Scholar
  • 15 Menzies D. Sputum induction: simpler, cheaper, and safer – but is it better?. Am J Respir Crit Care Med 2003; 167: 676-677
    CrossrefPubMedGoogle Scholar
  • 16 Donoghue HD, Holton J. Intestinal tuberculosis. Curr Opin Infect Dis 2009; 22: 490-496
    CrossrefPubMedGoogle Scholar
  • 17 al KarawiMA, Mohamed AE, Yasawy MI et al. Protean manifestation of gastrointestinal tuberculosis: report on 130 patients. J Clin Gastroenterol 1995; 20: 225-232
    CrossrefPubMedGoogle Scholar
  • 18 Klimach OE, Ormerod LP. Gastrointestinal tuberculosis: a retrospective review of 109 cases in a district general hospital. Q J Med 1985; 56: 569-578
    PubMedGoogle Scholar
  • 19 Bastani B, Shariatzadeh MR, Dehdashti F. Tuberculous peritonitis – report of 30 cases and review of the literature. Q J Med 1985; 56: 549-557
    PubMedGoogle Scholar
  • 20 Muneef MA, Memish Z, Mahmoud SA et al. Tuberculosis in the belly: a review of forty-six cases involving the gastrointestinal tract and peritoneum. Scand J Gastroenterol 2001; 36: 528-532
    CrossrefPubMedGoogle Scholar
  • 21 Manohar A, Simjee AE, Haffejee AA et al. Symptoms and investigative findings in 145 patients with tuberculous peritonitis diagnosed by peritoneoscopy and biopsy over a five year period. Gut 1990; 31: 1130-1132
    CrossrefPubMedGoogle Scholar
  • 22 Purohit MR, Mustafa T, Sviland L. Detection of Mycobacterium tuberculosis by polymerase chain reaction with DNA eluted from aspirate smears of tuberculous lymphadenitis. Diagn Mol Pathol 2008; 17: 174-178
    CrossrefPubMedGoogle Scholar
  • 23 Amarapurkar DN, Patel ND, Amarapurkar AD et al. Tissue polymerase chain reaction in diagnosis of intestinal tuberculosis and Crohn’s disease. J Assoc Physicians India 2004; 52: 863-867
    PubMedGoogle Scholar
  • 24 Li JY, Lo ST, Ng CS. Molecular detection of Mycobacterium tuberculosis in tissues showing granulomatous inflammation without demonstrable acid-fast bacilli. Diagn Mol Pathol 2000; 9: 67-74
    CrossrefPubMedGoogle Scholar
  • 25 Misra SP, Dwivedi M, Misra V et al. Endoscopic biopsies from normal-appearing terminal ileum and cecum in patients with suspected colonic tuberculosis. Endoscopy 2004; 36: 612-616
    Article in Thieme ConnectPubMedGoogle Scholar
  • 26 Lee WK, Van Tonder F, Tartaglia CJ et al. CT appearances of abdominal tuberculosis. Clin Radiol 2012; 67: 596-604
    CrossrefPubMedGoogle Scholar
  • 27 Cooper J, Fluckiger B, Traichl B et al. Abdominal pain in a patient with ankylosing spondylitis under treatment with infliximab. J Clin Rheumatol 2009; 15: 244-246
    CrossrefPubMedGoogle Scholar
  • 28 Ertekin V, Selimoglu MA, Okcu N et al. Intestinal tuberculosis mimicking Crohn's disease. J Emerg Med 2007; 33: 421-423
    CrossrefPubMedGoogle Scholar
  • 29 Maitra RK, Bowling T, Venkatesan P et al. Crohn’s disease or TB – the perennial question and diagnostic pitfalls. BMJ Case Rep 2012; 2012
    PubMedGoogle Scholar
  • 30 Sibartie V, Kirwan WO, O'Mahony S et al. Intestinal tuberculosis mimicking Crohn's disease: lessons relearned in a new era. Eur J Gastroenterol Hepatol 2007; 19: 347-349
    CrossrefPubMedGoogle Scholar
  • 31 Basar O, Koklu S, Koksal D et al. Intracranial tuberculomas in a nonimmuncompromised patient with abdominal tuberculosis misdiagnosed as Crohn's disease. Dig Dis Sci 2005; 50: 1279-1282
    CrossrefPubMedGoogle Scholar
  • 32 Philpott HL, Boussioutas A, Kronborg I et al. Education and imaging. Gastrointestinal tuberculosis of the sigmoid colon – a cautionary tale. J Gastroenterol Hepatol 2011; 26: 1692
    CrossrefPubMedGoogle Scholar
  • 33 Yaghoobi R, Khazanee A, Bagherani N et al. Gastrointestinal tuberculosis with anal and perianal involvement misdiagnosed as Crohn’s disease for 15 years. Acta Derm Venereol 2011; 91: 348-349
    CrossrefPubMedGoogle Scholar
  • 34 Baldin B, Dozol A, Spreux A et al. [Tuberculosis and infliximab treatment. National surveillance from January 1, 2000, through June 30, 2003]. Presse Med 2005; 34: 353-357
    CrossrefPubMedGoogle Scholar
  • 35 Thoen C, Lobue P, de Kantor I. The importance of Mycobacterium bovis as a zoonosis. Vet Microbiol 2006; 112: 339-345
    CrossrefPubMedGoogle Scholar
  • 36 Wallis RS. Tumour necrosis factor antagonists: structure, function, and tuberculosis risks. Lancet Infect Dis 2008; 8: 601-611
    CrossrefPubMedGoogle Scholar
  • 37 Torres-Gonzalez P, Soberanis-Ramos O, Martinez-Gamboa A et al. Prevalence of latent and active tuberculosis among dairy farm workers exposed to cattle infected by Mycobacterium bovis. PLoS Negl Trop Dis 2013; 7: e2177
    CrossrefPubMedGoogle Scholar
  • 38 Shaikha SA, Mansour K, Riad H. Reactivation of tuberculosis in three cases of psoriasis after initiation of anti-TNF therapy. Case Rep Dermatol 2012; 4: 41-46
    CrossrefPubMedGoogle Scholar
  • 39 Azevedo VF, Paiva E, Tosin T et al. Splenic tuberculosis in a patient with ankylosing spondylitis treated with adalimumab. Reumatismo 2011; 63: 171-174
    PubMedGoogle Scholar
  • 40 Nalbant S, Ozyurt M, Yildirim M et al. Pulmonary tuberculosis and tuberculous arthritis of knee joint associated with rheumatoid arthritis treated with anti-tumor necrosis factor (TNF)-alpha medication: a case report. Rheumatol Int 2012; 32: 2863-2866
    CrossrefPubMedGoogle Scholar
  • 41 Hess S, Hospach T, Nossal R et al. Life-threatening disseminated tuberculosis as a complication of TNF-alpha blockade in an adolescent. Eur J Pediatr 2011; 170: 1337-1342
    CrossrefPubMedGoogle Scholar
  • 42 Dignass A, Preiss JC, Aust DE et al. [Updated German guideline on diagnosis and treatment of ulcerative colitis, 2011]. Z Gastroenterol 2011; 49: 1276-1341
    Article in Thieme ConnectPubMedGoogle Scholar
  • 43 Hoffmann JC, Preiss JC, Autschbach F et al. [Clinical practice guideline on diagnosis and treatment of Crohn’s disease]. Z Gastroenterol 2008; 46: 1094-1146
    Article in Thieme ConnectPubMedGoogle Scholar
  • 44 Raval A, Akhavan-Toyserkani G, Brinker A et al. Brief communication: characteristics of spontaneous cases of tuberculosis associated with infliximab. Ann Intern Med 2007; 147: 699-702
    CrossrefPubMedGoogle Scholar
  • 45 Vassilopoulos D, Tsikrika S, Hatzara C et al. Comparison of two gamma interferon release assays and tuberculin skin testing for tuberculosis screening in a cohort of patients with rheumatic diseases starting anti-tumor necrosis factor therapy. Clin Vaccine Immunol 2011; 18: 2102-2108
    CrossrefPubMedGoogle Scholar
  • 46 Sharma SK, Mohan A, Sharma A et al. Miliary tuberculosis: new insights into an old disease. Lancet Infect Dis 2005; 5: 415-430
    CrossrefPubMedGoogle Scholar
  • 47 Rudwaleit M, Baeten D. Ankylosing spondylitis and bowel disease. Best Pract Res Clin Rheumatol 2006; 20: 451-471
    CrossrefPubMedGoogle Scholar