A SHOCKING CASE OF DISSEMINATED TB

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: BH is a 41-year-old Nepalese male with a history of ulcerative colitis (recently on adalimumab) and type two diabetes mellitus was transferred for the evaluation of ECMO. He presented to an outside hospital two days prior with a complaint of fevers, hemoptysis, and five-pound weight loss over one month. Despite pre-biologic testing showing indeterminate interferon, negative acid fast culture and a normal chest x-ray, a CT scan of his chest revealed diffuse miliary pattern, consistent with tuberculosis. CASE PRESENTATION: On arrival, the patient was intubated and required norepinephrine, vasopressin and phenylephrine to maintain mean arterial pressures over 65 mmHg. White blood cell count was 5.75 K/uL, lactic acid was 6.5 mmol/L, troponin was 0.5 ng/mL, brain natriuretic peptide was 66,716 pg/mL, ALT of 2827 unit/L and AST greater than 7000 unit/L, concerning for shock. Patient was anuric for which continuous renal replacement therapy was initiated. An echocardiogram showed an ejection fraction of 20-25%. Dobutamine was started due to a rising lactate despite adequate blood pressure. Patient was not a candidate for ECMO given presumed TB infection. Patient was started on Amikacin, Moxifloxacin, Meropenem, Ethambutol and Amphotericin. After a week, he was weaned from pressors and was extubated. He also regained renal function. A repeat echocardiogram two weeks following demonstrated improvement of ejection fraction to 50%. Acid fast bacillus testing confirmed tuberculosis. DISCUSSION: Adalimumab, a TNF-α inhibitor, are among biologic medications that are used in treatment of ulcerative colitis. Although one of its main infectious complications is tuberculosis, there can be other side effects including initiation of heart failure, cytopenia, and elevated transaminases [4]. All mentioned side effects may worsen the clinical picture of septic shock. There are only a handful of cases, some in pediatric literature [3], that conveys the degree of sepsis related to disseminated tuberculosis. Most literature of disseminated tuberculosis are often in the setting of human immunodeficiency virus or in pediatrics [4]. CONCLUSIONS: This case highlights the atypical presentation of disseminated tuberculosis masquerading as septic shock in the setting of recent adalimumab use. Despite the negative screen, it may be possible to develop tuberculosis during biologic therapy. Our case suggests that it may be of utility to retest for tuberculosis during therapy in individuals who may be at high risk for developing tuberculosis or those with indeterminant interferon results. REFERENCE #1: George S, Papa L, Sheils L, Magnussen CR. Septic shock due to disseminated tuberculosis. Clin Infect Dis. 1996 Jan;22(1):188-9. doi: 10.1093/clinids/22.1.188. PMID: 8825004. REFERENCE #2: Hess S, Hospach T, Nossal R, Dannecker G, Magdorf K, Uhlemann F. Life-threatening disseminated tuberculosis as a complication of TNF-α blockade in an adolescent. Eur J Pediatr. 2011 Oct;170(10):1337-42. doi: 10.1007/s00431-011-1501-y. Epub 2011 May 31. PMID: 21625932. REFERENCE #3: Mark S. Godfrey, Lloyd N. Friedman, Tuberculosis and Biologic Therapies: Anti-Tumor Necrosis Factor-α and Beyond, Clinics in Chest Medicine, Volume 40, Issue 4, 2019, Pages 721-739, ISSN 0272-5231, ISBN 9780323682152, https://doi.org/10.1016/j.ccm.2019.07.003.[4] Scheinfeld N. Adalimumab: a review of side effects. Expert Opin Drug Saf. 2005 Jul;4(4):637-41. doi: 10.1517/14740338.4.4.637. PMID: 16011443. DISCLOSURES: No relevant relationships by Saad Ashraf, source=Web Response No relevant relationships by Fiyad Haniff, source=Web Response No relevant relationships by ANDRY VAN DE LOUW, source=Web Response