Prolonged paradoxical reaction to antituberculous treatment after discontinuation of TNF-alpha- blocker therapy with adalimumab. Rare clinical documentation

Abstract

In the past decades, tumor necrosis factor alpha (TNF-a) antagonist has been a milestone in the treatment of many chronic inflammatory diseases. TNF antagonist can increase patients´ susceptibility to many different kinds of infections especially those requiring granuloma formations despite regular performance of Screening for latent tuberculosis infection (LTBI). We report 2 cases of patients who developed tuberculosis under treatment with adalimumab, which was discontinued after the diagnosis of tuberculosis. During the tuberculosis therapy they unexpectedly developed a prolonged paradoxical reaction. In both cases we were only able to manage the progress of the paradoxical reaction through high steroid doses. Patients undergoing therapy with TNF- alphablocker are prone to develop tuberculosis infection, which could in turn lead to severe prolonged paradoxical reaction during anti-tuberculous treatment. An increased steroid dose may be required and is sometimes necessary

Keywords

• Adalimumab
• Paradoxical reaction
• IRIS (immune reconstitution inflammatory syndrome)
• SAPHO (synovitis
• acne
• pustulosis
• hyperostosis
• osteitis) syndrome
• latent tuberculosis infection (LTBI)
• Tuberculosis (TB)
• IGRA (Interferon Gamma Release Assay)
• TNF (tumor necrosis factor)