DISEMINATED TUBERCULOSIS WITH BONE MARROW INVOLVEMENT AFTER THE USE OF ANTI-TNF
Abstract
Introduction: Tuberculosis can affect individuals undergoing immunosuppressive treatments. The use of anti-TNF predisposes to its reactivation and presentation in disseminated forms.
Case presentation: A 41-year-old male with a history of psoriasis treated with anti-TNF presented an increase in abdominal diameter, with positive ascitic wave, negative ascitic fluid culture, and peritoneal biopsy showing caseating granulomas. He was readmitted for dyspnea and epistaxis, pancytopenia was detected requiring transfusions of blood products, granulocyte stimulators, and corticosteroids. Pulmonary micronodules and unilateral pleural effusion were identified in a thoracic CT scan. Bronchoalveolar lavage was performed, and Lowenstein culture identified Mycobacterium tuberculosis, with bone marrow biopsy revealing granulomas with caseous necrosis. He started antitubercular treatment with blood count recovery and required thoracotomy for hemothorax evacuation. He will complete 9 months of antitubercular treatment.
Discussion and literature review: TNF-α blockade can cause tuberculosis disease, with bacterial dissemination via lymphohematogenous route, affecting various organs. Peritoneal tuberculosis represents 2% of ascites, manifesting with abdominal pain and distension, weight loss, and fever. Ascitic fluid analysis may show leukocytes, proteins > 2.5 g/dl, and SAAG < 1.1 g/L. In bone marrow dissemination, pancytopenia can be rare, with positive culture between 8-48%. Histopathological studies in various locations may show necrotizing or caseous granulomas.
Conclusions: Tuberculosis disease or infection should be ruled out before initiating immunosuppressive drugs, and in the presence of atypical symptoms in these patients, tuberculosis should be among the suspected diagnoses.
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