DOI:10.2214/AJR.05.0412
AJR 2006; 186:1799-1800
© American Roentgen Ray Society
Pseudotumoral Colonic Tuberculosis Complicating Rheumatoid Arthritis Treated with a Tumor Necrosis Factor Antagonist
Alvian Lesnik,
Julie Bolivar,
Jacques Morel and
Patrice Taourel
Hôpital Lapeyronie
Montpellier 34295, France
There has been marked recent progress in the treatment of inflammatory
diseases, especially rheumatoid arthritis, with the development of new drugs
such as tumor necrosis factor (TNF) antagonists
[1]. These new therapies are
highly promising for patients presenting with severe rheumatoid arthritis
resistant to conventional therapies, but they have potential side effects that
have not yet been completely assessed. The use of TNF antagonist increases the
risk of infectious granulomatous diseases such as tuberculosis and
histoplasmosis [2]. Such
diseases may arise in unexpected locations. Here we present a case of a
patient undergoing infliximab treatment complicated by digestive tuberculosis
originating in an atypical location, the transverse colon.
In a 67-year-old woman with long-standing rheumatoid arthritis, infliximab
treatment had been prescribed because the disease was not responding to
corticosteroids and methotrexate. The patient had no risk factor for
tuberculosis and was studied with a skin tuberculin test before introducing
infliximab.
Three months later, the patient developed a fever that never exceeded
38.5°C with a concomitant weight loss of 4 kg. The laboratory findings
revealed an increase in inflammatory markers. A body CT examination was
performed to screen for possible deep infectious or tumoral complications. The
abdominal CT scan showed a focal circumferential and slightly irregular
thickening of the transverse colon wall with homogeneous attenuation. Moderate
pericolonic fat infiltration was also noted
(Fig. 2A). There were no
indications of bowel obstruction, and no lymph node enlargement or ascites was
detected.
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Fig. 2A —67-year-old woman treated with infliximab (tumor necrosis factor
[TNF]- antagonist) for severe rheumatoid arthritis and presenting with
recent weight loss, mild fever, and high levels of inflammatory markers.
Abdominal contrast-enhanced CT image shows focal, slightly asymmetric
transverse colon wall thickening with homogeneous attenuation
(arrows).
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Fig. 2B —67-year-old woman treated with infliximab (tumor necrosis factor
[TNF]- antagonist) for severe rheumatoid arthritis and presenting with
recent weight loss, mild fever, and high levels of inflammatory markers.
Sonogram, sagittal view, shows that colon wall is hypoechoic and homogeneous.
Individual layers of colon are not visible.
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A sonography examination was performed to analyze the colon wall and
revealed that the thickening was hypoechoic and homogeneous
(Fig. 2B). No other digestive
abnormalities were detected on CT or sonography. Thoracic CT slices did not
highlight any abnormalities. The macroscopic endoscopic observations indicated
the presence of an ulcerated stenosis located 65 cm from the anus. Biopsy
revealed a granulomatous tuberculoma deeply inside the chorion.
Mycobacterium tuberculosis was detected through bacteriologic
sampling examinations and cultures. The patient was started on a standard
four-drug antituberculous disease treatment. Fever and weight loss stopped,
and 4 months after the beginning of the treatment, a CT examination revealed
that bowel wall thickening had decreased. A colonoscopy is scheduled at the
end of the treatment.
Recent reports have claimed that latent tuberculosis may be reactivated in
patients undergoing treatment with TNF- antagonists, especially
infliximab rather than etanercept
[1,
2]. Two kinds of mechanisms are
usually described to explain tuberculous infection. First, a recent infection
due to direct contamination. Second, a latent infection that occurred several
years earlier may be reactivated in cases of host immunity depression.
TNF-, an inflammatory cytokine expressed by activated macrophages, T
cells, and other immune cells, is essential for granuloma formation and
maintenance, which are key components of host defenses against M.
tuberculosis and other intracellular pathogens
[2,
3]. The reactivation hypothesis
is supported by the fact that a significant number of cases have been reported
in which the disease has developed less than 3 months after the institution of
infliximab therapy.
Digestive tuberculosis is rarely encountered in western Europe and North
America and is preferentially located in the ileocecal region
[4,
5]. In patients with thickening
of the bowel wall, defining the type of thickening via sonography and CT may
help to establish the correct diagnosis. CT shows the degree of thickening;
symmetric versus asymmetric thickening; focal, segmental, or diffuse
involvement; and associated perienteric abnormalities
[6]. In a patient presenting
with a focal asymmetric colon wall thickening with homogeneous attenuation, a
neoplasm is the first diagnosis to consider. However, none of these CT
findings is very specific, so the clinical context is important for
interpretation. When an infection is suspected, colonoscopy is the technique
of choice to perform wall biopsies and recover bacteriologic samples for
direct examination and cultures.
Radiologists should be aware that infectious granulomatous diseases and
tuberculosis should be considered in cases of digestive wall thickening in
patients undergoing TNF- antagonist treatment. Patients prescribed this
kind of therapy should have close clinical, biologic, and imaging
follow-up.
References
- Keane J, Gershon S, Wise RP, et al. Tuberculosis associated with
infliximab: a tumor necrosis factor alpha-neutralizing agent. N
Engl J Med 2001; 345:1098
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- Wallis RS, Broder MS, Wong JY, Hanson ME, Beenhouwer DO.
Granulomatous infectious diseases associated with tumor necrosis factor
antagonists. Clin Infect Dis 2004;38
: 1261-1265[CrossRef][Medline]
- Centers for Disease Control and Prevention. Tuberculosis associated
with blocking agents against tumor necrosis factor-alpha: California,
2002-2003. MMWR Morb Mortal Wkly Rep2004; 53:683
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- Harisinghani MG, McLoud TC, Shepard JA, Ko JP, Shroff MM, Mueller
PR. Tuberculosis from head to toe. RadioGraphics2000; 20:449
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