Toh Ming Ren, Tan Sophie Seine Xuan, Angela Takano, Ong Thun How
Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore.
Department of Infectious Diseases, Singapore General Hospital, Singapore, Singapore.
BMC Infect Dis. 2025 May 2;25(1):648. doi: 10.1186/s12879-025-11047-6.
A 76-year-old gentleman with chronic plaque psoriasis was found to have a right lower lobe mass with bilateral pulmonary nodules, extensive lymphadenopathy, splenic hypodensities and diffuse peritoneal thickening on the computed tomography (CT) scan 5 months after initiation of adalimumab. Biopsies of the RLL mass and supraclavicular lymph node showed granulomatous inflammation and cultures were positive for Mycobacterium tuberculosis (MTB). Adalimumab was stopped and he was started on TB treatment. He remained well and asymptomatic but was noted to have 3 kg weight loss. Interval CT scan 3 months later showed enlarging mediastinal lymph nodes confluent with a new left lower lobe endobronchial mass. Sputum, bronchoalveolar lavage and bronchial biopsy samples were negative for evidence of active TB. Histology showed granulation tissue with both acute and chronic inflammation. Diagnostic impression was asymptomatic TB immune reconstitution inflammatory syndrome (IRIS), and he was maintained on the existing TB treatment. Interval CT 1 month later showed resolution of the endobronchial mass. In patients without human-immunodeficiency virus (HIV) infection, IRIS after initiation of TB treatment is rare. Without standardised diagnostic criteria, TB IRIS can be challenging to diagnose especially in absence of clinical symptoms. Patients with TB IRIS can have serious complications but may also be asymptomatic with only radiological abnormalities. Hence a high clinical suspicion is needed for the diagnosis, especially in patients presenting initially with disseminated disease or with underlying immune dysregulation such as in this patient who had been on anti- TNF-α treatment. Exclusion of alternative diagnoses is important. Our case also highlights the importance of a personalised approach (with combination tests) especially among immunosuppressed patients with prior TB disease.
一名76岁患有慢性斑块状银屑病的男性患者，在开始使用阿达木单抗5个月后的计算机断层扫描（CT）中发现右下叶肿块，伴有双侧肺结节、广泛淋巴结病、脾脏低密度影和弥漫性腹膜增厚。右下叶肿块和锁骨上淋巴结活检显示肉芽肿性炎症，结核分枝杆菌（MTB）培养呈阳性。停用阿达木单抗并开始抗结核治疗。他病情稳定且无症状，但体重减轻了3千克。3个月后的间隔CT扫描显示纵隔淋巴结肿大，并与新出现的左下叶支气管内肿块融合。痰液、支气管肺泡灌洗和支气管活检样本均未发现活动性结核的证据。组织学显示为伴有急性和慢性炎症的肉芽组织。诊断印象为无症状性结核免疫重建炎症综合征（IRIS），继续接受现有抗结核治疗。1个月后的间隔CT显示支气管内肿块消退。在无人类免疫缺陷病毒（HIV）感染的患者中，开始抗结核治疗后出现IRIS的情况罕见。由于缺乏标准化诊断标准，结核IRIS尤其在无临床症状时诊断具有挑战性。结核IRIS患者可能出现严重并发症，但也可能仅表现为影像学异常而无症状。因此，诊断需要高度的临床怀疑，特别是对于最初表现为播散性疾病或存在潜在免疫失调的患者，如该接受抗TNF-α治疗的患者。排除其他诊断很重要。我们的病例还强调了个性化方法（联合检测）的重要性，特别是在既往有结核病史的免疫抑制患者中。
