Use of steroids to treat anti-tumor necrosis factor α induced tuberculosis-associated immune reconstitution inflammatory syndrome

Abstract

Introduction: Individuals with tuberculosis (TB) who are being treated with anti-tumor necrosis factor α (anti-TNFα) for coexisting conditions may experience unexpected exacerbations of TB after the initiation of antituberculous therapy, so-called anti-TNFα-induced TB-immune reconstitution inflammatory syndrome (anti-TNFα-induced TB-IRIS). Anti-TNFα-induced TB-IRIS is often treated empirically with corticosteroids; however, the evidence of the effectiveness of corticosteroids is lacking and the management can be a challenge. Patient concerns: A 32-year-old man on long-term infliximab therapy for Crohn disease visited a clinic complaining of persistent fever and cough that had started 1 week previously. His most recent infliximab injection had been administered 14 days before the visit. A chest X-ray revealed a left pleural effusion, and he was admitted to a local hospital. Diagnosis: A chest computed tomography (CT) scan revealed miliary pulmonary nodules; acid-fast bacilli were found in a sputum smear and a urine sediment sample; and polymerase chain reaction confirmed the presence of Mycobacterium tuberculosis in both his sputum and the pleural effusion. He was diagnosed with miliary TB. Interventions: Antituberculous therapy was started and he was transferred to our hospital for further management. His symptoms initially improved after the initiation of antituberculous therapy, but 2 weeks later, his symptoms recurred and shadows on chest X-ray worsened. A repeat chest CT scan revealed enlarged miliary pulmonary nodules, extensive ground-glass opacities, and an increased volume of his pleural effusion. This paradoxical exacerbation was diagnosed as TB-IRIS associated with infliximab. A moderate-dose of systemic corticosteroid was initiated [prednisolone 25 mg/day (0.5 mg/kg/day)]. Outcomes: After starting corticosteroid treatment, his radiological findings improved immediately, and his fever and cough disappeared within a few days. After discharge, prednisolone was tapered off over the course of 10 weeks, and he completed a 9-month course of antituberculous therapy uneventfully. He had not restarted infliximab at his most recent follow-up 14 months later. Conclusion: We successfully managed a patient with anti-TNFα-induced TB-IRIS using moderate-dose corticosteroids. Due to the limited evidence currently available, physicians should consider the necessity, dosage, and duration of corticosteroids for each case of anti-TNFα-induced TB-IRIS on an individual patient-by-patient basis.

TB@PLGA Nanoparticles for Photodynamic/Photothermal Combined Cancer Therapy with Single Near-Infrared Irradiation

“…Toluidine blue play s a profound role in the field of medicine. It can be used as a nucleic acid dye for the detection of tumors in a clinic setting, 17 , 18 and as a safe and effective photosensitive material for both PDT and PTT. 19 However, it is aggregates easily at high concentrations, and the generation of polymers affects the photosensitivity.…”

Paradoxical worsening of nontuberculous mycobacterial disease after the discontinuation of antitumor necrosis factor therapy: A case report

“…The cases of anti-TNF–associated tuberculosis-IRIS have often been reported [ 2 ], whereas those of anti-TNF–associated NTM-IRIS are rare. In a previous case series of 13 patients with anti-TNF–associated NTM pulmonary disease, no patient was IRIS [ 7 ].…”

“…Steroid dosage was increased, and treatment was subsequently completed [ 10 ]. Although the number of cases of anti-TNF–associated NTM-IRIS is insufficient, the clinical presentation of such patients might be mild compared to that of patients with anti-TNF–associated tuberculosis-IRIS [ 2 ]. Some of the patients from the reviewed case reports and the present patient had received cytotoxic drugs in addition to TNF inhibitors.…”

“…The use of anti-TNF therapy has increased the incidence of anti-TNF–associated tuberculosis [ 1 ]. It has further led to a rise in the cases of anti-TNF–associated tuberculosis-immune reconstitution inflammatory syndrome (IRIS) [ 2 ]. Moreover, the incidence of anti-TNF–associated nontuberculous mycobacteria (NTM) disease has increased [ 3 ]; however, anti-TNF–associated NTM-IRIS has rarely been reported.…”

Clinical manifestations of Whipple’s disease mimicking rheumatic disorders

“…It has been reported that Tropheryma whipplei exerts suppression on CD4+ T-cells and the syndrome can develop after antibiotic medication [ 20 ]. Glucocorticoids are drugs of choice in patients with immune reconstitution inflammatory syndrome [ 56 ].…”