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Tuberculosis infection in rheumatic patients with infliximab therapy: experience with 157 patients

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Abstract

It is recommended to evaluate the presence of latent tuberculosis infection (LTBI) prior to the use of antitumor necrosis factor α. The aim of this study is to assess the presence of LTBI in patients with rheumatic diseases undergoing treatment with infliximab in an endemic area for tuberculosis (TB). LTBI was searched through the contact history, chest X-ray and tuberculin skin test with purified protein derivative (PPD) ≥5 mm. We studied 157 patients in the period from May 2005 to October 2008, 99 (63.1%) were women with average age of 49 years and 58 (36.9%) were men with average age of 41 years. The group comprising 90 patients (57.3%) with rheumatoid arthritis (RA), 54 (34.4%) with ankylosing spondylitis (AS) and 13 (8.3%) with psoriatic arthritis (PsA) had PPD reactor 13.4% (21/157), being prevented by isoniazid (INH) in these patients. There are dissimilar responsiveness to the PPD between the three pathologies, and the reactivity was lower in RA (RA × AS: χ2 = 12; P = 0.0004; and RA × PsA: χ2 with Yates’ correction = 3.6; P = 0.05). No significant difference between the reactivity of the PPD and the use of immunosuppressive drugs (P = 0.81) is observed. The immunoprophylaxis with INH showed an efficacy of 95% (20/21); three (1.9%) patients developed active TB (spondylodiscitis, meningitis and lymphadenopathy) after the use of infliximab, reaffirming extrapulmonary involvement. These results suggest that PPD has a low sensitivity for detection of LTBI in RA and that the previous use of immunosuppressive drugs does not affect the response to PPD.

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References

  1. Keane J, Gershon S, Wise RP et al (2001) Tuberculosis associated with infliximab, a tumor necrosis factor alpha-neutralizing agent. N Engl J Med 345:1098–1104

    Article  PubMed  CAS  Google Scholar 

  2. Ormerod LP, Milburn HJ, Gillespie S, Ledingham J, Rampton D (2005) BTS recommendations for assessing risk and managing Mycobacterium tuberculosis infection and disease in patients due to start anti-TNFa treatment. Thorax 60:800–805

    Article  Google Scholar 

  3. Hanta I, Ozbek S, Kuleci S, Kocabas A (2008) The evaluation of latent tuberculosis in rheumatologic diseases for anti-TNF therapy: experience with 192 patients. Clin Rheumatol 27:1083–1086

    Article  PubMed  Google Scholar 

  4. Ministério da Saúde (2010) Programa Nacional de Controle da Tuberculose—Manual de Recomendações para o Controle da Tuberculose no Brasil. http://portal.saude.gov.br/portal/arquivos/pdf/manual_de_recomendacoes_controle_tb_novo.pdf. Accessed 06 Oct 2010

  5. Ehrenstein MR, Evans JG, Singh A et al (2004) Compromised function of regulatory T cells in rheumatoid arthritis and reversal by anti-TNF-α therapy. J Exp Med 200:277–285

    Article  PubMed  CAS  Google Scholar 

  6. Ponce de León D, Acevedo-Vásquez E, Sánchez-Torres A et al (2005) Attenuated response to purified protein derivate in patients with rheumatoid arthritis: study in a population with high prevalence of tuberculosis. Ann Rheum Dis 64:1360–1361

    Article  PubMed  Google Scholar 

  7. Filho AC, Kritski AL, Barreto AW et al (2004) II Consenso brasileiro de tuberculose. Diretrizes brasileiras para tuberculose. J Bras Pneumol 30(1):1–55

    Article  Google Scholar 

  8. Façanha MC, Guerreiro MFF, Pinheiro AC et al (2003) Resgate de casos subnotificados de tuberculose em Fortaleza-CE, 2000–2002. Bol Pneumol Sanit 11(2):13–16

    Google Scholar 

  9. Seong SS, Choi CB, Woo JH et al (2007) Incidence of tuberculosis in Korean patients with rheumatoid arthritis itself and tumor necrosis factor blocks. J Rhematol 34:706–711

    CAS  Google Scholar 

  10. Silva JB Jr (2004) Tuberculose: Guia de Vigilância Epidemiológica. J Bras Pneumol 30:57–85

    Google Scholar 

  11. Gomez-Reino JJ, Carmona L, Descalzo A, BIOBADASER GROUP (2007) Risk of tuberculosis in patients treated with tumor necrosis factor antagonists due to incomplete prevention of reactivation of latent infection. Arthritis Rheum 57(5):756–761

    Article  PubMed  CAS  Google Scholar 

  12. Panayi G, Corrigal V, Pitzalis C (2001) Pathogenesis of rheumatoid arthritis. The role of cells and others beasts. Rheum Dis Clin North Am 161:221–247

    Google Scholar 

  13. Corrigal VM, Garyfallos A, Panayi GS (1999) The relative proportions of secreted interleukin-2 and interleukin-10 determine the magnitude of rheumatoid arthritis T-cell proliferations to the recall antigen tuberculin purified protein derivative. Rheumatology 38:1203–1207

    Article  Google Scholar 

  14. Emery P, Panayi G, Symmons D, Brown G (1984) Mechanisms of depressed delayed-type hypersensitivity in rheumatoid arthritis: the role of protein energy malnutrition. Ann Rheum Dis 43:430–434

    Article  PubMed  CAS  Google Scholar 

  15. Kingsley GH, Pitzalis C, Panay GS (1987) Abnormal lymphocyte reactivity to self-major histocompatibility antigens in rheumatoid arthritis. J Rheumatol 14:667–673

    PubMed  CAS  Google Scholar 

  16. Marques CDL, Duarte ALBP, Lorena VMB et al (2009) Resposta atenuada ao PPD no diagnóstico de infecção tuberculosa latente em pacientes com artrite reumatóide. Rev Bras Reumatol 49(2):121–131

    Article  Google Scholar 

  17. Laurindo IMM, Seiscento M, Bombardia S et al (2004) Diagnosis of latent tuberculosis in rheumatoid arthritis (RA) patients: tuberculin test (PPD) assessment. EULAR, Rheumatoid arthritis clinical aspects [THU0235]. http://www.abstracts2view.com/eular/sessionindex.php?session=2004374&day=2004. Accessed 27 Jan 2010

  18. Andrade TCB, Maia RM, Cosgrove C, Castelo Branco LRR (2005) BCG Moreau Rio de Janeiro–An oral vaccine against tuberculosis–review. Men Inst Oswaldo Cruz 100(5):459–465

    Article  Google Scholar 

  19. Maciel ELN, Viana MC, Zeitoune RCG, Ferreira I, Fregona G, Dietze R (2005) Prevalence and incidence of Mycobacterium tuberculosis infection in nursing students in Vitória, Espírito Santo. Rev Soc Bras Med Trop 38(6):469–472

    Article  PubMed  Google Scholar 

  20. Pilsczek FH, Kaufmann SHE (2008) Prevalence and predictors of positive tuberculin skin test results in a research laboratory. Rev Soc Bras Med Trop 41(4):416–418

    Article  PubMed  Google Scholar 

  21. Köker IH, Pamuk ÖN, Karlikaya C, Tunçbilek N, Çakir N (2007) A low prevalence of purified protein derivative test positivity in Turkish patients with rheumatoid arthritis. Association with clinical features and HRCT findings. Clin Exp Rheumatol 25:54–59

    PubMed  Google Scholar 

  22. Pinheiro MM, Melo MR, Jennings MF, Barbosa CP, Terreri MT, Hilário MOE (2010) Positividade do teste tuberculínico em crianças e adultos com artropatias inflamatórias crônicas e indicação para o uso de terapia anti-TNF. Congresso Brasileiro de Reumatologia 2010, Artrite reumatóide/epidemiologia e aspectos clínicos. Rev Bras Reumatol 50(1):84

    Google Scholar 

  23. Pereira SM, Dantas OMS, Ximenes R, Barreto ML (2007) Vacina BCG contra tuberculose: efeito protetor e políticas de vacinação. Rev Saúde Pública 41(Supl. 1):59–66. http://www.scielosp.org/pdf/rsp/v41s1/6492.pdf. Accessed 08 Oct 2010

  24. Saito M, Bautista CT, Gilman RH, Bowering A, Levy MZ, Evans CA (2004) The value of counting BCG scars for interpretation of tuberculin skin tests in a tuberculosis hyperendemic shantytown, Peru. Int J Tuberc Lung Dis 8(7):842–847

    PubMed  CAS  Google Scholar 

  25. Provenzano G, Ferrante MC, Simon G (2005) TB screening and anti-TNF α treatment. Thorax 60:612–615

    Article  Google Scholar 

  26. Sellam J, Hamdi H, Roy C et al (2007) Comparison of in vitro-speciWc blood tests with tuberculin skin test for diagnosis of latent tuberculosis before anti-TNF therapy. Ann Rheum Dis. doi:10.1136/ard.2007.069799

  27. Dheda K, Udwadia ZF, Huggett JF, Johnson MA, Rook GA (2005) Utility of the antigen-specific interferon-gamma assay for the management of tuberculosis. Curr Opin Pulm Med 11(3):195–202

    Article  PubMed  CAS  Google Scholar 

  28. Marques CDL, Duarte ALBP, Lorena VMB et al (2009) Evaluation of an interferon gamma assay in the diagnosis of latent tuberculosis infection in patients with rheumatoid arthritis. Rheumatol Int 30:57–62

    Article  PubMed  CAS  Google Scholar 

  29. Montoro M, Gonzalez C, López-Longo FJ et al (2009) New PPD-positive test during infliximab treatment. ACR Annual meeting, Abstract 135. http://acr.confex.com/acr/2009/webprogram/paper15520.html. Accessed 26 Nov 2010

  30. Cush JJ, Winthrop K, Dao K et al (2010) ACR Safety Committee. Screening for Mycobacterium tuberculosis Infection: questions and answers for clinical practice. http://www.rheumatology.org/publications/dsq/dsq_2010_02.pdf. Accessed 26 Nov 2010

  31. Cooray D, Moran R, Broumand A et al (2009) Serial re-screening in high risk patients on anti-TNF &alpha therapy validate CDC recommendations of monitoring TB risk. ACR annual meeting, Abstract 1153. http://acr.confex.com/acr/2009/webprogram/paper15478.html. Accessed 26 Nov 2010

  32. Fuchs I, Avnon L, Freud T, Abu-Shakra M (2009) Repeated tuberculin skin testing following therapy with TNF-alpha inhibitors. Clin Rheumatol 28(2):167–172

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Rheumatology Division, Hospital Geral de Fortaleza, Fortaleza, CE, Brazil

    Christiane Aguiar Nobre, Maria Roseli Monteiro Callado, José Rubens Costa Lima, Kirla Wagner Poti Gomes, Germana Vasconcelos Mesquita Martiniano & Walber Pinto Vieira

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  1. Christiane Aguiar Nobre
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  2. Maria Roseli Monteiro Callado
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  3. José Rubens Costa Lima
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Correspondence to Christiane Aguiar Nobre.

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Nobre, C.A., Callado, M.R.M., Lima, J.R.C. et al. Tuberculosis infection in rheumatic patients with infliximab therapy: experience with 157 patients. Rheumatol Int 32, 2769–2775 (2012). https://doi.org/10.1007/s00296-011-2017-5

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  • DOI: https://doi.org/10.1007/s00296-011-2017-5

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