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

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

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