Assante Luca Rosario, Barra Enrica, Bocchino Marialuisa, Zuccarini Giacomo, Ferrara Gerardo, Sanduzzi Alessandro
Section of Respiratory Diseases, Department of Surgery and Clinical Medicine, University Federico II, Naples; Unit of Pathology, AORN Ospedali dei Colli, Naples, Italy; Unit of Pathology, AO G. Rummo, Benevento, Italy.
Infez Med. 2014 Jun;22(2):144-8.
In recent years Tumor Necrosis Factor alpha (TNF alfa) inhibitors have been highly effective in treating rheumatoid arthritis (RA). However, patients receiving these inhibitors have an increased risk of developing tuberculosis (TB). We describe a rare case of tuberculosis of the tongue in an RA patient treated with methotrexate (MTX) and the TNF alfa inhibitor adalimumab (ADA) for the previous six years. Pretreatment tuberculin skin test (TST) was negative. The patient was admitted to our division complaining of a sore throat for months. Clinical examination revealed a swollen non-healing ulcer at the base of the tongue, which was suspected to be a squamous cell carcinoma. Histopathological assessment unexpectedly revealed a chronic granulomatous inflammation compatible with tuberculosis. TST was strongly positive and the T Spot TB test was also reactive. MTX and ADA were discontinued and the patient received antituberculous treatment with complete healing of the lesion. After three months our patient had a worsening RA that was treated with MTX and rituximab with no TB related adverse events. This case highlights the importance of considering tuberculosis in the differential diagnosis of ulcerative lesions of the oral cavity, especially in immunocompromised patients treated with TNF alfa inhibitors. Rituximab can be a valid alternative therapy in such patients.
近年来，肿瘤坏死因子α（TNFα）抑制剂在治疗类风湿性关节炎（RA）方面疗效显著。然而，接受这些抑制剂治疗的患者患结核病（TB）的风险增加。我们描述了一例罕见的舌部结核病例，该患者为一名类风湿性关节炎患者，此前六年一直使用甲氨蝶呤（MTX）和TNFα抑制剂阿达木单抗（ADA）进行治疗。治疗前结核菌素皮肤试验（TST）为阴性。该患者因数月来咽痛而入住我科。临床检查发现舌根部有一个肿胀且不愈合的溃疡，怀疑为鳞状细胞癌。组织病理学评估意外发现为与结核病相符的慢性肉芽肿性炎症。TST呈强阳性，T-SPOT.TB检测也呈阳性反应。停用MTX和ADA，患者接受抗结核治疗，病变完全愈合。三个月后，我们的患者类风湿性关节炎病情恶化，接受了MTX和利妥昔单抗治疗，未出现与结核相关的不良事件。该病例凸显了在口腔溃疡性病变的鉴别诊断中考虑结核病的重要性，尤其是在接受TNFα抑制剂治疗的免疫功能低下患者中。利妥昔单抗可能是这类患者的一种有效替代疗法。
