Colonic Sarcoidosis, Infliximab, and Tuberculosis: A Cautionary Tale

Abstract

The antitumor necrosis factor, infliximab, has been recently shown to be effective in refractory sarcoidosis including the intestinal form of this disease. We have tried this therapy in a 55-year-old woman under immunosuppressive therapy for longstanding sarcoidosis presenting with abdominal pain apparently caused by a colonic localization of the disease. The latter diagnosis was based, as recommended, on the presence of nonnecrotizing granulomas in mucosal biopsies, the presence of systemic disease, and the careful exclusion of other granulomatous diseases, including tuberculosis. After the first IV infusion (10 mg/kg BW), she quickly improved, but the wellbeing lasted approximately 4 weeks. She then received another dose of infliximab, but she soon developed low-grade fever and weakness and shortly succumbed of miliary tuberculosis. Likely, infliximab precipitated a pre-existing mycobacterial infection of the intestine. Given the likelihood of underdiagnosing intestinal tuberculosis--and the risks associated with infliximab treatment--this case suggests that this drug should be used with extreme caution, if at all, when a diagnosis of colonic sarcoidosis is suspected.

Making a Positive Diagnosis of Intestinal Tuberculosis with the Aid of New Biologic and Histologic Features: How Far Have We Reached?

“…Thoracic adenopathy, other systemic features, and a negative TB culture may lead to suspicion of this relatively rare disease. However, histological examination of large specimens may yield the final diagnosis [6-8]. …”

Digestive-tract sarcoidosis

“…The digestive tract is a rare localization of tuberculosis, [44] which may be fatal if the diagnosis is missed and immunosuppressive drugs are introduced. [45] …”

Colon Sarcoidosis Responds to Methotrexate: A Case Report with Review of Literature

“…These agents are being utilized in refractory cases and the duration of therapy is limited because of long-term sequale. The only death reported was a result of miliary tuberculosis after initiation of infliximab, despite careful exclusion of a prior infectious etiology [21]. Fortunately, there are no reports of death directly related to colon sarcoidosis.…”

“…Our medline search resulted in 22 well-documented cases of colon sarcoid published from 1949 to 2008. Included in our analysis is the case we present, totaling to date 23 cases[2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21]. The…”