Presentation
Being treated for psoriatic arthritis with adalimumab. Presents with deranged liver function tests and fevers.
Patient Data
PA and lateral chest x-rays demonstrate wide spread small (2-4mm) nodular opacities distributed throughout both lungs.
CT of the chest confirms the presence of innumerable small pulmonary nodules, which have a centrilobular predilection. Dependent changes are also present. The mediastinum is unremarkable.
CT of the upper abdomen demonstrates splenomegaly with multiple hypo-attenuating nodules, best seen on the portal venous phase.
This patient went on to have a bronchoscopy with bronchial washings obtained.
MICROSCOPY: Auramine-Rhodamine Stain: No Acid Fast Bacilli Detected. A negative acid-fast smear result does not exclude the presence of Mycobacterium species.
ANTIGEN TESTING: MPT64 Antigen: M.tuberculosis Complex DETECTED
NUCLEIC ACID TESTING: DNA Amplification Assay for M.tuberculosis Complex: DETECTED
MYCOBACTERIUM CULTURE
- MGIT bottle (9 days): POSITIVE
- Mycobacterium tuberculosis: ISOLATED
SENSITIVITIES
- Ethambutol: sensitive
- Isoniazid: sensitive
- Pyrazinamide: sensitive
- Rifampin: sensitive
Case Discussion
Adalimumab (along with infliximab and etanercept) is a TNF inhibitor. As of 2008 adalimumab has been approved by the FDA for the treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn's disease, moderate to severe chronic psoriasis and juvenile idiopathic arthritis.
Although most easily seen in the lungs, miliary TB is a systemic illness with solid organs also affected. In this case splenic and hepatic involvement is evident.
This patient went on to receive appropriate systemic antibiotics.
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