Infliximab and Tuberculosis, and case presentation

We treated a young man suffering from ankylosing spondylitis with Infliximab. The risk for developing tuberculosis is well known. He is 24 years of age and has a Eastern European migratory background. Ankylosing of the sacroiliac joints already is pronounced. He is also suffering from advanced secondary osteoarthritis of both hip joints and peripheral arthritis. Morning stiffness lasted 2-3 hours.

BASDAI (Bath Ankylosing Spondylitis Disease Activity Index): 7,8.
BASFI (Bath Ankylosing Spondylitis Functional Index): 9.
BASMI (Bath Ankylosing Spondylitis Metrology Index): 4.

HLA B27 positive. Testing with IGRA (Interferon-Gamma Release Assay) has been negative as well as serologic markers for Hepatitis B and C. Initial CRP 124.3 mg/l and ESG 61 mm.

X-ray of the hip joints and the sacroiliac joints

After initiating a therapy with methotrexate due to peripheral arthritis, we also initiated infliximab at 5 mg/kg body weight, which was 300 mg.
Medication: 1-0-1 ibuprofene 400 mg 20 mg pantozole; 10 mg Methotrexat s.c. per week, followed two days later by 5 mg folic acid.

Follow up showed a happy patient with a CRP 2.4 mg/l and ESG 14 mm; leucocytes dropped to 3.5 /nl, however.

BASDAI (Bath Ankylosing Spondylitis Disease Activity Index): 4,0.
BASFI (Bath Ankylosing Spondylitis Functional Index): 3,8.
BASMI (Bath Ankylosing Spondylitis Metrology Index): 1,0.
All three indices showed a remarkable improvement under infliximab.

After the 5th infusion with infliximab, he developed shortness of breath, fatigue, loss of energy, and a dry cough, so that he had to be admitted to our hospital.
Lab: CRP 147.3 mg/l and ESG 41 mm. Testing with IGRA (Interferon-Gamma Release Assay) has been positive now.
Transbrochial biopsy and lavage didn’t show acid-fast organisms, but granuloma and a tuberculosis positive PCR.
A fourfold tuberculostatic therapy has been started and the patient is doing fine.

Chest X-rays from before treatment with infliximab, after developing tuberculosis, and after three weeks of therapy:

TNF-alpha inhibitors need pre-treatment screening, but one also has to keep being alerted during therapy. Tuberculosis is a threat, but can be managed if diagnosed rapidly. The question remain, however, what we will do after the tuberculostatic therapy as our patient still is suffering from a severe form of ankylosing spondylitis.