Chest / Cardiac for Tuesday, April 8th, 2025

History

18-year-old girl with night fever and mild headache.
Underlying Crohn's disease, on infliximab.

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Question

What is the most likely diagnosis?

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Correct answer

Miliary tuberculosis following infliximab therapy for Crohn disease

Discussion

Infliximab (TNF-α antagonist)

• Chimeric immunoglobulin G (IgG) monoclonal antibody targeting TNF-a. 
• Effective treatment for steroid dependant, fistulizing Crohn's disease. 
• Risk of disseminations of intracellular pathogens normally controlled by the cell mediated granulomatous inflammatory process and potential reactivation of Tuberculosis.

According to the report by Keane et al (N Engl J Med 2001;345:1098-104). 

• Until 2001, 70 reported cases of TB among the approximately 147,000 ,000 treated patients, a frequency much higher than the reported frequency of other opportunistic infections. 
• Received treatment for a median of 12 weeks. 
• In 48 patients, TB developed after 3 or fewer infusions. 
• Extrapulmonary disease occurred in 40 patients (17 with disseminated disease) 
• 64/70 were from countries with low incidence of TB 

References

• Keane et al, N Engl J Med 2001;345:1098-104.