Background: Increased risk of tuberculosis (Tb) during tumor necrosis factor alpha (TNFa) antagonist therapy is one of severe problems in patients with Crohn's disease. It is usually presented as pulmonary manifestation, sometimes miliary Tb. But, extra-pulmonary Tb has been rarely reported in case of Crohn's disease. Here in, we present a case of unusual presentation of Tb in a patient with Crohn's disease after anti- TNFa therapy. Case report: A 21-year-old male was diagnosed as Crohn's disease, two years ago. Oral corticosteroid therapy was initial treatment. He complained a nausea after azathioprine administration and oral mesalazine could not improve the Crohn's disease. Because of disease progression, anti-TNFa therapy was started one year ago. Tb Screening test was negative at that time. Crohn's disease was improved after infliximab induction. After 6 month, he admitted to hospital due to right lower abdominal pain. Any other symptom except abdominal pain was not shown and chest X-ray was unremarkable. There was no evidence of appendicitis or Crohn's disease aggravation in abdominal CT. But, multiple nodules were shown in spleen (Figure 1), which were suspected Tb, fungal infection, or lymphoma. (Figure presented) Although abdominal pain was subsided by conservative treatment, Tb screening test was performed for differential diagnosis of Tb. Unexpectedly, rechecked PPD test and Tb specific Ag showed positive. Consolidation of left upper lung was newly found in follow up chest X-ray and high resolution CT (Figure 2). (Figure presented) Percutaneous needle lung biopsy was done and Tb was confirmed by histopathologic feature of necrotizing granulomatous inflammation. Therefore, anti-TNFa therapy was immediately stopped, Tb therapy with 4 regimens (INH, RFP, EMB, and PZA) was continued until now. The size and number of splenic lesions were decreased after Tb therapy and Crohn's disease did not aggravate during the follow up period. Conclusions: Although Tb screening is negative, the risk of Tb cannot be completely excluded. During anti-TNFa therapy, we must have in mind the possibility of atypical Tb infection. Tb may occur without definite lung lesion. In patients with non-specific symptoms, image modality like as ultrasonography should be considered for early detection of extra-pulmonary TB. Also, more accurate test might be routinely performed, especially in Tb endemic area.
Jeen, Y. T., Lee, J. M., Choi, H. S., Kim, E. S., Keum, B., & Chun, H. J. (2014). P105 Unusual presentation of tuberculosis as splenic nodules in a patient with Crohn’s disease. Journal of Crohn’s and Colitis, 8, S106. https://doi.org/10.1016/s1873-9946(14)60227-0