Disseminated Tuberculosis in an Immunocompromised Pediatric Patient

Introduction Tuberculosis (TB) in children receiving immunosupresants, such as tumor necrosis factor α inhibitors (TNFis), is rare; however, these patients are at an increased risk for severe TB disease and significant long-term morbidity [1]. We present a case of disseminated TB in a child with a history of juvenile idiopathic arthritis (JIA) who had been treated with adalimumab. Case Presentation A 7 year old girl was admitted to Lithuanian University of Health Sciences Kaunas Hospital Tuberculosis department in March 2023 due to persistent febrile fever and a miliary pattern observed in a chest X-ray. At the age of 3 the patient was diagnosed with polyarticular juvenile idiopathic arthritis (JIA) and treated with methotrexate and adalimumab. The diagnosis of pulmonary TB was confirmed by positive GeneXpert MTB/RIF and interferon gamma release assay (IGRA) tests. The treatment of JIA was discontinued and standart anti-TB treatment with rifampicin, isoniazid, pyrazinamide, and ethambutol was initiated. After 3 months of inpatient treatment, the child was discharged and continued the outpatient treatment as well as regular follow-up visits to evaluate the disease activity. Due to the patient’s immunocompromised state and no radiographic improvement shown by chest CT scans, the anti-TB treatment was prolonged. After 14 months of treatment, widespread abdominal calcifications in the mesentery lymph nodes and spleen were detected, confirming the diagnosis of disseminated TB. Therefore treatment with rifampicin and ethambutol was continued. Nonetheless, the last follow-up CT scan showed no radiographic improvement and persistent patchy areas of consolidation in the lungs, hilar, mediastinal and axillary lymphadenopathy and lymph node calcification. Currently, at 9 years old, the patient is still undergoing anti-TB treatment. Discussion TNFis impair the human host's immune response to TB by suppressing the activation of macrophages, which are responsible for killing TB or isolating it through granuloma formation [2]. This case highlights the great severity of TB disease in children receiving TNFis, consistent with cases described in a large multicenter study [1]. Conclusions Patients treated with TNFis are at increased risk of severe TB disease, therefore routine latent TB infection screening prior to anti-TNF-α therapy is crucial.