Letter: recommendations for the management of latent tuberculosis infection in IBD patients may not be applicable in all settings – author's reply

Abstract

et al., where the conversion and reversion rates of screening tests for latent tuberculosis (LTB) of patients under antitumour necrosis factor-alpha (TNF-a) therapy were tested. In this context, we present a case report of a Caucasian, 26-year-old woman, with no travelling history to endemic areas for tuberculosis, nor close contact with tuberculosis patients. She had Crohn’s disease diagnosed in 2009, with a nonreactive tuberculin skin test (TST) at the time. In January 2011, azathioprine was started, but interrupted due to acute pancreatitis. Five months later, another TST was performed and repeated 14 days later, according to national standards of care. 3 Both were nonreactive. The chest radiograph remained unchanged. Infliximab was then initiated, but the third infusion was not performed because of fever, dry cough and asthaenia. The TST had a 27-mm induration and the interferon gamma release assay (IGRA) was positive. CT chest, the histology of supraclavicular adenopathy and Ziehl-Neelsen were compatible with disseminated tuberculosis, and polymerase chain reaction was positive for Mycobacterium tuberculosis. The patient began tuberculosis treatment and was afebrile at the 2nd day of therapy. We question the role of the negativity of TST even in the absence of immunosuppression, and support the Austrian guidelines on LTB screening that omit TST as a screening test. According to these recommendations, only 42% of the originally treated patients would have received chemoprophylaxis with isoniazid. 5 Perhaps the patient described in this letter could belong to the remaining 58% and could have been saved from disseminated tuberculosis if IGRA had been performed prior to TNF-a therapy.