Abstract
Emerging anti-tumor necrosis factor (TNF)-α antibodies therapy changed treatment strategy to inflammatory bowel diseases because of the efficacy. However, TNF-α inhibitor can be associated with an increased risk of infectious complications, especially tuberculosis. A 71-year-old female with steroid-dependent ulcerative colitis (UC) was admitted due to relapse of UC with endoscopically severe active. Golimumab and adjunctive prednisolone started with 30 mg daily resulted in clinical remission. However, she had general fatigue and fever at the time of seventh injection of golimumab without abdominal symptoms. Based on positive interferon-gamma release assay, polymerase chain reaction positive for tuberculosis (TB) in pleural fluid, and chest computed tomography, she was diagnosed as tuberculous pleuritis. Standard anti-TB treatment (isoniazid, rifampicin, ethambutol, and pyrazinamide) was started without cessation of golimumab, because cessation of TNF-α inhibitors during anti-TB treatment could cause the paradoxical response by skewing from regulatory to inflammatory immune responses. However, four weeks after initiation of anti-TB treatment, she got fever-up and pleural effusion increased. We then started prednisolone 30 mg daily as diagnosis of paradoxical response, resulting in improving the symptoms. This is a suggestive case of paradoxical response during anti-TB treatment despite continuous TNF-α inhibitors.
Similar content being viewed by others
References
Mao EJ, Hazlewood GS, Kaplan GG, et al. Systematic review with meta-analysis: comparative efficacy of immunosuppressants and biologics for reducing hospitalisation and surgery in Crohn’s disease and ulcerative colitis. Aliment Pharmacol Ther. 2017;45:3–13.
Zhang Z, Fan W, Yang G, et al. Risk of tuberculosis in patients treated with TNF-alpha antagonists: a systematic review and meta-analysis of randomised controlled trials. BMJ Open. 2017;7:e012567.
Park DI, Hisamatsu T, Chen M, et al. Asian Organization for Crohn’s and Colitis and Asia Pacific Association of Gastroenterology consensus on tuberculosis infection in patients with inflammatory bowel disease receiving anti-tumor necrosis factor treatment. Part 2: management. Intest Res. 2018;16:17–25.
Garcia Vidal C, Rodriguez Fernandez S, Martinez Lacasa J, et al. Paradoxical response to antituberculous therapy in infliximab-treated patients with disseminated tuberculosis. Clin Infect Dis. 2005;40:756–9.
Rivoisy C, Amrouche L, Carcelain G, et al. Paradoxical exacerbation of tuberculosis after TNFalpha antagonist discontinuation: beware of immune reconstitution inflammatory syndrome. Jt Bone Spine. 2011;78:312–5.
Murdaca G, Spano F, Contatore M, et al. Infection risk associated with anti-TNF-alpha agents: a review. Expert Opin Drug Saf. 2015;14:571–82.
Ng SC, Shi HY, Hamidi N, et al. Worldwide incidence and prevalence of inflammatory bowel disease in the 21st century: a systematic review of population-based studies. Lancet. 2017;390:2769–78.
Ford AC, Peyrin-Biroulet L. Opportunistic infections with anti-tumor necrosis factor-alpha therapy in inflammatory bowel disease: meta-analysis of randomized controlled trials. Am J Gastroenterol. 2013;108:1268–76.
Navarra SV, Tang B, Lu L, et al. Risk of tuberculosis with anti-tumor necrosis factor-alpha therapy: substantially higher number of patients at risk in Asia. Int J Rheum Dis. 2014;17:291–8.
Keane J, Gershon S, Wise RP, et al. Tuberculosis associated with infliximab, a tumor necrosis factor alpha-neutralizing agent. N Engl J Med. 2001;345:1098–104.
Pai M, Behr M. Latent mycobacterium tuberculosis infection and interferon-gamma release assays. Microbiol Spectr. 2016;4:4–5.
Park DI, Hisamatsu T, Chen M, et al. Asian Organization for Crohn’s and Colitis and Asian Pacific Association of Gastroenterology consensus on tuberculosis infection in patients with inflammatory bowel disease receiving anti-tumor necrosis factor treatment. Part 1: Risk assessment. J Gastroenterol Hepatol. 2018;33:20–9.
Singh J, Puri AS, Sachdeva S, et al. Rectal tuberculosis after infliximab therapy despite negative screening for latent tuberculosis in a patient with ulcerative colitis. Intest Res. 2016;14:183–6.
Quinn CM, Poplin V, Kasibante J, et al. Tuberculosis IRIS: pathogenesis, presentation, and management across the spectrum of disease. Life (Basel). 2020;10:262.
Cevaal PM, Bekker LG, Hermans S. TB-IRIS pathogenesis and new strategies for intervention: Insights from related inflammatory disorders. Tuberculosis (Edinb). 2019;118:101863.
Namale PE, Abdullahi LH, Fine S, et al. Paradoxical TB-IRIS in HIV-infected adults: a systematic review and meta-analysis. Future Microbiol. 2015;10:1077–99.
Watanabe S, Kaneko Y, Kawamoto H, et al. Paradoxical response with increased tumor necrosis factor-alpha levels to anti-tuberculosis treatment in a patient with disseminated tuberculosis. Respir Med Case Rep. 2017;20:201–4.
Matsumoto T, Tanaka T. Continuation of anti-TNF therapy for rheumatoid arthritis in patients with active tuberculosis reactivated during anti-TNF medication is more beneficial than its cessation. J Infect Dis Ther. 2015;3:35–7.
Rahier JF, Magro F, Abreu C, et al. Second European evidence-based consensus on the prevention, diagnosis and management of opportunistic infections in inflammatory bowel disease. J Crohns Colitis. 2014;8:443–68.
Acknowledgements
This study received no specific funding and grants.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Informed consent
Informed consent was obtained from the patient for this case report.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Hosomi, S., Sugita, N., Kanamori, A. et al. A case of paradoxical response during anti-tuberculosis treatment in a patient with ulcerative colitis. Clin J Gastroenterol 15, 592–597 (2022). https://doi.org/10.1007/s12328-022-01616-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12328-022-01616-6