AB0170 TUBERCULOSIS IN PATIENTS WITH SYSTEMIC RHEUMATIC DISEASES : THE TUNISIAN EXPERIENCE

Abstract

Background: The incidence of tuberculosis among patients with systemic rheumatic diseases is much higher than in the general population. The clinical manifestations of both systemic rheumatic disease activity and tuberculosis, (i.e. fever, weight loss, asthenia) may overlap or lead to confusion. The immunosuppression of systemic diseases makes the management of patients with tuberculosis more complicated. Objectives: The purpose of our study was to describe the clinical characteristics of patients with systemic rheumatic diseases and tuberculosis. Methods: A retrospective study, from 1998 to 2018, in the internal medicine service in Fattouma Bourguiba hospital, Tunisia, of 59 patients suffering from connective tissues disease, treated by corticosteroids linked in one or several treatments to immunosuppressants, who subsequently developed tuberculosis. Results: Fifty nine patients were included (46 women and 13 man) with a mean age of 47years (range from 18-83 years). Systemic illnesses were: systemic lupus erythematous (13.6%, n = 8), Gougerot-Sjogren syndrome (secondary or primary) (18.6%, n = 11), systemic scleroderma (5.1%, n = 3), rheumatoid arthritis (n = 1), Takayasu arteritis (n=1), Horton disease (n=2), periarteritis nodosa (n=1), Wegener’s granulomatosis (n= 2) and Behcet’s disease (n=1). 45 patients (76.6%) were treated with corticosteroids and/or immunosuppressants in 3 cases (methotrexate in one case, cyclophosphamide in one case and azathioprine in one case) before the tuberculosis was diagnosed. The clinical manifestations most commonly observed were : weight loss in 55.9%, fatigue in 50.8% and fever in 24.7%. The tuberculin skin tets was positive in 45.8%. Quantiferon-TB-Gold was positive in eleven cases. Twelve patients had an abnormal chest X-ray. The location of the tuberculosis was pulmonary (32.3%, n = 19), ganglionic (33.9%, n = 16), urogenital (20.3%, n = 12), lymphatic (n = 5), abdominal (n=4), cerebral (n=2), ocular (n=2), osteoarticular (n= 2) and more than one location in 23.7% of the cases. The diagnosis of tuberculosis was confirmed by bacteriology in 13,6% (n = 8) and in thirteen cases, histologically (22.03%).The systemic rheumatic disease was clinically active at the time of the diagnosis of tuberculosis in 8 patients.The diagnosis of systemic rheumatic diseases was made before that of tuberculosis in 13 patients and concomitantly in 5. Under tuberculosis treatment by four drugs then by two drugs, the evolution of tuberculosis was favourable in most of our patients. Three of the patients developed an allergy in isoniazid. Nine patients have developped hepatotoxicity with pyrazinamide. Retrobulbar neuritis was observed in 3 cases treated with ethambutol. Conclusion: This study confirms the often extra-pulmonary character of tuberculosis in patients with systemic disease as well as the difficulty of diagnosis and problems multiplied by this association. The screening strategies for tuberculosis should probably be extended in all patients with systemic rheumatic diseases receiving glucocorticoids and/or immunosuppressive therapy.