Reactivation of tuberculosis under immunosuppression with TNF

Thema: Der besondere Fall
FA.11
Reactivation of tuberculosis under immunosuppression with TNF- α inhibitors due to
Mycobacterium bovis infection of the oral mucosa
Ernst D.1, Bange F.-C.2, Rana M.3, Baerlecken N.4, Puls F.5, Schmidt R.E.4, Stoll M.6
(1) Medizinische Hochschule Hannover, Klinik für Immunologie und Rheumatologie, , (2) Medizinische
Hochschule Hannover (MHH), Institut für Mikrobiologie und Krankenhaushygiene, Hannover, (3)
Medizinische Hochschule Hannover (MHH), Klinik für Mund-, Kiefer- und Gesichtschirurgie, Hannover, (4)
Medizinische Hochschule Hannover (MHH), Klinik für Immunologie und Rheumatologie, Hannover, (5)
Medizinische Hochschule Hannover (MHH), Institut für Pathologie, Hannover, (6) Medizinische Hochschule
Hannover, Hannover
Fragestellung
History:
A 70 year old patient receiving TNF- α inhibitor therapy for chronic polyarthritis - initially Etanercept (4years),
with subsequent switch to Adalimumab, due to treatment failure - was admitted 13 months after beginning
Adalimumab to our maxillo-facial surgery department.
Main symptoms:
Oral ulceration and persisting mucosal swelling in the left maxilliary sinus, which demonstrated further
progression despite antibiotic and antiviral treatment.
Examination and Investigation:
Multiple mucosal biopsies were taken, with histological examination revealing necrotising granulomatous
inflammation suspicious of mycobacterial infection. Pathological examination subsequently revealed 2 acidfast bacilli.
An Interferon-gamma Release Assay (IGRA) was performed and returned positive. Concurrent
microbiological cultures confirmed the diagnosis of tuberculosis.
Treatment:
The patient was isolated for two weeks, whilst a quadruple therapy with isoniazide, rifampin, ethambutol, and
pyrazinamide was initiated. A rapid clinical improvement ensued.
Further microbiological sub-typing using 16s-RNA sequencing confirmed the species as Mycobacterium
bovis. Due to confirmation of typical pyraminazide-resistance, this drug was replaced by moxifloxacin.
Consequences:
When investigating treatment-refractory infections and ulceration, particularly within immunosuppressed
populations, consideration should always be given to mycobacterial infections.
Detailed and directed history taking are vital in determining at-risk patients. Ideally this should be conducted
during the initial assessment for TNF- α inhibitor suitability. In the case presented, the patients husband had
previously suffered from confirmed tuberculosis in 1952 and both the patient and her husband had previously
lived on a farm with a large herd of cattle.