S2264 Tuberculous Pericardial Tamponade in the Patient With Crohn’s Disease Treated With Adalimumab

Abstract

INTRODUCTION: Adalimumab is an anti-tumor necrosis factor alpha (anti-TNF) medication used for the treatment of moderate-to-severe Crohn’s disease and ulcerative colitis. Tuberculosis (TB) has remained a serious side effect of anti-TNF therapy despite routine TB screening. We report a case of a young male who developed disseminated TB with cardiac tamponade while being treated with adalimumab for Crohn’s disease. CASE DESCRIPTION/METHODS: A 34-year-old male with a history of Crohn’s colitis who emigrated from Central America 15 years ago presented to the ED complaining of fever to 104 F with chest pain, shortness of breath, and cough for three days. He had been on adalimumab 40 mg SC every two weeks for the past 6 months. Prior to starting adalimumab, screening for TB with an interferon gamma release assay (IGRA) on two occasions was negative. He had not received any immunosuppressive therapy before IGRA testing. Considering the COVID-19 pandemic, the symptoms were suspicious for SARS-CoV-2 infection, but PCR was negative. Chest x-ray revealed the right upper lobe infiltrate and cardiac enlargement (Figure 1). Echocardiography confirmed pericardial effusion with hemodynamic compromise which required an emergent pericardiocentesis with removal of 1,200 ml of pericardial fluid. Histopathological evaluation of pericardium showed poorly formed granuloma (Figure 2). Repeat IGRA and further testing for HIV, histoplasma and cryptococcus antigen were negative. Pericardial fluid and bronchoalveolar lavage cultures showed growth of M.tuberculosis. Adalimumab was discontinued and anti-tuberculosis treatment was started with improvement in symptoms. DISCUSSION: TB is a known risk factor with anti-TNF therapy in IBD patients, with extrapulmonary or disseminated forms in up to 60% of cases and should not be missed in the wake of the COVID-19 pandemic. Tuberculous pericardial tamponade is an unusual manifestation of extrapulmonary TB in IBD patients undergoing anti-TNF therapy, with only one case previously reported in the English literature. The optimal screening of latent TB before anti-TNF therapy remains a challenge, and false-negative IGRAs can occur in 0.4–0.7 % of IBD patients. Therefore, IGRA should be repeated twice and could be accompanied with a chest x-ray or tuberculin skin test for patients exposed to occupational risks and/or travelers to endemic countries. Some guidelines recommend prophylaxis of latent TB with isoniazid for high risk patient groups before anti-TNF therapy regardless of a negative IGRA result.Figure 1.: Chest x-ray showing right upper lobe infiltrate and cardiac enlargement.Figure 2.: Histopathology of pericardium showing fibrin deposits and poorly formed granuloma.