Correspondence

Infliximab for Rheumatoid Arthritis in a Patient with Tuberculosis

N Engl J Med 2006; 355:740-741August 17, 2006

Article

To the Editor:

Tumor necrosis factor α antagonists have been shown to be effective agents in the treatment of rheumatoid arthritis; however, they have also been shown to increase the risk of the reactivation of tuberculosis in patients with latent infection1,2 and may render the tuberculosis refractory to drug therapy.3,4 Decisions regarding the treatment of patients with refractory rheumatoid arthritis in the setting of active tuberculosis remain difficult.

A 64-year-old woman with a 10-year history of rheumatoid arthritis (functional class III and radiologic stage 3, according to Steinbrocker's criteria) had begun treatment with infliximab at a dose of 3 mg per kilogram of body weight combined with prednisolone (10 mg per day), sulfasalazine (1000 mg per day), and methotrexate (8 mg per week) because of worsening joint symptoms (Figure 1Figure 1Clinical Course of a Woman with Rheumatoid Arthritis and Active Peritoneal Tuberculosis.). At baseline, she had a nonreactive tuberculin skin test with purified protein derivative, and the results of computed tomography of the chest were normal. After the third administration of infliximab, high fever and abdominal distention developed.

The patient was referred to our hospital, and a diagnosis of peritoneal tuberculosis was established. A standard antituberculosis regimen was initiated (isoniazid, rifampin, pyrazinamide, and ethambutol), and prednisolone and methotrexate were continued without infliximab. Drug testing showed that the Mycobacterium tuberculosis collected from a specimen of abdominal fluid was susceptible to all the medications tested. Intensive antituberculosis therapy resulted in the resolution of the clinical signs and symptoms of peritoneal tuberculosis, but the cessation of infliximab was associated with a recrudescence of highly symptomatic rheumatoid arthritis four months later. Given the excellent clinical response of the tuberculosis to therapy and the limited therapeutic options for the treatment of the patient's severely symptomatic rheumatoid arthritis, infliximab therapy was resumed in conjunction with continuing antituberculosis medication.

The readministration of infliximab resulted in prompt improvement in the disease activity of the rheumatoid arthritis (Figure 1), meeting the criteria of the American College of Rheumatology for remission. No signs of a recurrence of the tuberculosis have been detected after more than one year of follow-up. This case report demonstrates that infliximab therapy can be considered for patients with refractory rheumatoid arthritis who have recovered from active tuberculosis and in whom antituberculosis therapy can be maintained.

Tomoshige Matsumoto, M.D.
Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Osaka 583-8588, Japan
tom_matsumoto@sutv.zaq.ne.jp

Toshio Tanaka, M.D.
Ichiro Kawase, M.D.
Osaka University Medical School, Osaka 565-0871, Japan

4 References

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   Arthritis Advisory Committee. Update on the TNF-α blocking agents. Rockville, Md.: Food and Drug Administration, 2003. (Accessed July 27, 2006, at http://www.fda.gov/ohrms/dockets/ac/03/briefing/3930B1_01_B-TNF.Briefing.doc.)
   

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Citing Articles (12)

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   Shunsuke Mori, Mineharu Sugimoto. (2011) Is continuation of anti-tumor necrosis factor-α therapy a safe option for patients who have developed pulmonary mycobacterial infection?. Clinical Rheumatology
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   Alexis Guyot, Vincent Descamps, Béatrice Crickx. (2011) Mycobactérioses atypiques cutanées. Revue du Rhumatisme Monographies 78:3, 173-177
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   Naoto AZUMA, Mai MORIMOTO, Noriyuki TSUBOTA, Michinori SHIRANO, Takanori KUROIWA, Kazuyuki FUJITA, Takuya HINO, Mika OKABE-NOGAMI, Aki NISHIOKA, Ryota OKAZAKI, Masahiro SEKIGUCHI, Masayasu KITANO, Shinichiro TSUNODA, Hajime SANO. (2011) Tuberculous peritonitis during etanercept therapy for rheumatoid arthritis. Japanese Journal of Clinical Immunology 34:6, 501-509
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   In Tae Kim, Hyung Bok Park, Sang Hun Lee, Yu Kyung Hyun, Yun Ji Kim, Yong Won Lee, Jung-Soo Song, Sang Tae Choi. (2011) Tuberculous Peritonitis in a Patient with Rheumatoid Arthritis Treated with Infliximab. Journal of Rheumatic Diseases 18:4, 320
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   Toru Mori. (2009) Usefulness of interferon-gamma release assays for diagnosing TB infection and problems with these assays. Journal of Infection and Chemotherapy 15:3, 143-155
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   Jason A. Dare, Shormi Jahan, Kim Hiatt, Karina D. Torralba. (2009) Reintroduction of etanercept during treatment of cutaneous Mycobacterium marinum infection in a patient with ankylosing spondylitis. Arthritis & Rheumatism 61:5, 583-586
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   A. Perlmutter, A. Mittal, A. Menter. (2009) Tuberculosis and tumour necrosis factor-α inhibitor therapy: a report of three cases in patients with psoriasis. Comprehensive screening and therapeutic guidelines for clinicians. British Journal of Dermatology 160:1, 8-15
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   Jakko van Ingen, Martin J Boeree, PN Richard Dekhuijzen, Dick van Soolingen. (2008) Mycobacterial disease in patients with rheumatic disease. Nature Clinical Practice Rheumatology 4:12, 649-656
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   Robert S Wallis. (2008) Tumour necrosis factor antagonists: structure, function, and tuberculosis risks. The Lancet Infectious Diseases 8:10, 601-611
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    Joseph Keane, Barry Bresnihan. (2008) Tuberculosis reactivation during immunosuppressive therapy in rheumatic diseases: diagnostic and therapeutic strategies. Current Opinion in Rheumatology 20:4, 443-449
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    S. M. Arend, E. M. S. Leyten, W. P. J. Franken, E. M. Huisman, J. T. van Dissel. (2007) A Patient with De Novo Tuberculosis during Anti-Tumor Necrosis Factor--  Therapy Illustrating Diagnostic Pitfalls and Paradoxical Response to Treatment. Clinical Infectious Diseases 45:11, 1470-1475
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    Jakko van Ingen, Martin Boeree, Matthijs Janssen, Erik Ullmann, Wiel de Lange, Petra de Haas, Richard Dekhuijzen, Dick van Soolingen. (2007) Pulmonary Mycobacterium szulgai infection and treatment in a patient receiving anti-tumor necrosis factor therapy. Nature Clinical Practice Rheumatology 3:7, 414-419
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