Rapid immunodiagnosis of tuberculosis in a woman receiving anti-TNF therapy.

BACKGROUND

A 63-year-old German woman with a 24-year history of Crohn's disease and associated polyarthralgias presented with severe malaise, dyspnea, fever, night sweats, dry cough and an extensive right-sided pleural effusion. The patient had begun treatment with bi-weekly subcutaneous injections of adalimumab 5 weeks earlier.

INVESTIGATIONS

Physical examination, chest X-ray, transthoracic ultrasonography, pleural tap and drainage, bacterial and cytological analyses of pleural fluid, bronchoscopy, microscopy and bacteriological culture of pleural exudates and bronchoalveolar lavage fluid, thoracic CT, thoracoscopy, histopathology of pleural biopsy, tuberculin skin test, nucleic acid amplification of mycobacterial RNA and DNA in the pleural fluid specimens and the parietal pleural biopsy, microscopy of sputum samples, ESAT-6-specific and CFP-10-specific interferon-gamma enzyme-linked immunospot assay on peripheral blood and pleural exudate mononuclear cells.

DIAGNOSIS

Pulmonary and pleural tuberculosis.

MANAGEMENT

Cessation of adalimumab treatment. Initiation of quadruple antibiotic therapy with isoniazid, rifampin, ethambutol and pyrazinamide. Prednisolone administered to reduce the pleural effusion.