Abstract
BackgroundPatients undergoing anti-tumor necrosis factor (TNF) treatment are at an increased risk of reactivating a latent tuberculosis infection (LTBI). This study evaluated the effectiveness of the QuantiFERON-TB Gold In-Tube (QFT) assay for diagnosing LTBI in arthritis patients undergoing anti-TNF treatment.MethodsWe enrolled 342 consecutive patients from August 2007 to October 2013: 176 (51.5%) patients with ankylosing spondylitis and 166 (48.5%) with rheumatoid arthritis. Screening tests included tuberculin skin test (TST) and QFT assay. Positive QFT results, regardless of TST results, were considered an indicator for LTBI treatment.ResultsBacillus Calmette-Guérin scars were found in 236 (69.0%) patients. Of 342 patients, TST and QFT were positive in 122 (35.7%) and 103 (30.1%) patients, respectively, and discordant in 101 (29.5%) patients. During a median follow-up duration of 41.7 months, five patients (1.5%) developed TB in a median of 20.8 months after initiation of anti-TNF treatment (428/100,000 person-years). TB did not occur in 62 TST+/QFT+ patients who received LTBI treatment. Of 41 TST−/QFT+ patients who received LTBI treatment, one (2.4%) developed TB 20.5 months after starting anti-TNF treatment (705/100,000 person-years). Of 60 TST+/QFT− patients who did not receive LTBI treatment, two (3.3%) developed TB 20.8 and 22.0 months after starting anti-TNF treatment (871/100,000 person-years). Of 179 TST−/QFT− patients, two (1.1%) developed TB 7.2 and 22.7 months, respectively, after initiating anti-TNF treatment (341/100,000 person-years). TB incidence rate during the follow-up period did not differ among TST−/QFT+, TST+/QFT−, and TST−/QFT− patients (P = 0.661).ConclusionQFT might be used instead of TST for diagnosing LTBI in patients before starting anti-TNF therapy in countries, such as Korea, where the TB prevalence is intermediate and the BCG vaccination is mandatory at birth. In the absence of a true gold standard test for LTBI, however, there is still a risk of TB development during anti-TNF treatment.
Highlights
The introduction of biological agents such as anti-tumor necrosis factor (TNF)-α, has had a profound effect on the management of rheumatic arthritis, including both rheumatoid arthritis (RA) and ankylosing spondylitis (AS) [1, 2]
TB did not occur in 62 TST+/QuantiFERON-TB Gold In-Tube (QFT)+ patients who received latent tuberculosis infection (LTBI) treatment
QFT might be used instead of TST for diagnosing LTBI in patients before starting anti-TNF therapy in countries, such as Korea, where the TB prevalence is intermediate and the Bacillus Calmette-Guérin (BCG) vaccination is mandatory at birth
Summary
The introduction of biological agents such as anti-tumor necrosis factor (TNF)-α, has had a profound effect on the management of rheumatic arthritis, including both rheumatoid arthritis (RA) and ankylosing spondylitis (AS) [1, 2]. Because of the risk of developing active tuberculosis (TB) with use of TNF-α antagonists [3, 4], patients should be screened for latent tuberculosis infections (LTBI) before starting anti-TNF treatment [5, 6]. The TST may produce false-positive results owing to prior Bacillus Calmette-Guérin (BCG) vaccination or nontuberculous mycobacterial infection; this poor specificity can lead to unnecessary LTBI treatment, with the risk of drug toxicity [11, 12]. Either the inflammatory disorder itself or the immunosuppressive treatment may lead to false-negative TST results [13]. Patients undergoing anti-tumor necrosis factor (TNF) treatment are at an increased risk of reactivating a latent tuberculosis infection (LTBI). This study evaluated the effectiveness of the QuantiFERON-TB Gold In-Tube (QFT) assay for diagnosing LTBI in arthritis patients undergoing anti-TNF treatment
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