SHM Converge Scientific Abstract ePoster Gallery-Tuberculosis Reactivation Associated With Adalimumab Presenting With New Onset Ascites

Pdf Summary

This case describes a 51-year-old man with psoriasis who developed new abdominal distention, ascites, fever, weight loss, night sweats, cough, and shortness of breath after treatment with the TNF-alpha inhibitor adalimumab. He had a remote history of latent tuberculosis (TB) treated with 6 months of isoniazid and had previously lived in Mexico. A repeat QuantiFERON test became positive, and chest imaging showed new right upper lobe opacities, prompting discontinuation of adalimumab.<br /><br />On presentation, exam showed bibasilar crackles and ascites without signs of chronic liver disease. CT imaging demonstrated diffuse ascites with mesenteric inflammation, a normal liver, and chest findings of bilateral upper-lobe micronodules, consolidative opacities, mediastinal lymphadenopathy, and small pleural effusions. Paracentesis revealed lymphocyte-predominant ascitic fluid with low SAAG and elevated adenosine deaminase, suggestive of tuberculous peritonitis. Although TB PCR, AFB stains, and cultures were negative, the clinical suspicion remained high. Sputum AFB stains and fungal studies were also negative.<br /><br />He was started empirically on RIPE therapy plus pyridoxine for presumed reactivation TB.<br /><br />The report emphasizes that TNF-alpha inhibitors significantly increase the risk of TB reactivation because TNF is important for immune control of latent infection. It also highlights that microbiologic confirmation of extrapulmonary TB is often difficult, so treatment may need to begin based on clinical and radiographic evidence. The case further notes that TB symptoms may paradoxically worsen after stopping anti-TNF therapy, possibly due to immune reconstitution.

Asset Subtitle

Jacob L. Schmelz

Meta Tag

Author List Gregory Bowling, Jacob L. Schmelz

Category Clinical Vignettes

Concept Tuberculosis Reactivation

Concept Tuberculous Ascites

Concept RIPE Therapy

Concept TNF-alpha Inhibitor Therapy

Concept Latent Tuberculosis

Distinguished Non-Finalist

Presenter Organization UT Health San Antonio

Presenting Author Jacob L. Schmelz

Track Adult

Keywords

adalimumab

tuberculosis reactivation

psoriasis

tuberculous peritonitis

TNF-alpha inhibitor

ascites

QuantiFERON positive

RIPE therapy

mediastinal lymphadenopathy

immune reconstitution

Tuberculosis Reactivation

Tuberculous Ascites

RIPE Therapy

TNF-alpha Inhibitor Therapy

Latent Tuberculosis