A 37- year- old Indian man with diagnosed Psoriasis arthritis was treated with adalimumab on a regular basis. TB-Screening with IGRA (Interferon Gamma Release Assay) before the therapy with TNF- a- blocker tested negative.
He was diagnosed with severe disseminated miliary tuberculosis with extensive acute respiratory distress syndrome under treatment with adalimumab. Laboratory examination revealed initial CRP 10.3 mg/dl, LDH 489 U/L and Leukocyte with 14.0 GIGA/L. The initial contrast enhanced CT- Scan revealed severe progressive bilateral pulmonary infiltrates (Fig.3a). During that period, intensive care was required. After the first treatment course of two weeks antituberculosis treatment with four antibiotics (INH isonicotinic acid hydracide 300 mg daily, RIFA rifampicin 600 mg daily, PZA pyrazinamide 2000 mg daily and SM streptomycin 1000 mg daily), the contrast enhanced CT scan showed regressive bilateral pulmonary infiltrates (Fig.3b). Under the tuberculosis therapy, the laboratory parameters were also improved after 2 weeks of treatment; CRP 2.8 mg/dl, LDH 203 U/L and Leukocyte was 12.1 GIGA/L.
During the treatment of tuberculosis therapy, therapy with TNF- alpha- blocker adalimumab was discontinued. Six weeks after the discontinuation of the adalimumab therapy, he developed a prolonged paradoxical reaction with reverse episodes of fever, elevation of CRP 7.1 mg/dl; Leukocyte of 16.0 GIGA/L and LDH of 276 U/L. and progressive bilateral pulmonary infiltration which were revealed in both contrast enhanced CT-scan and chest x- ray (Fig. 4, 5).
Multiple blood cultures rendered no clear evidence of pathogen agents. HIV- test was again tested negative. Not until the initiation of steroid prednisolone therapy with a daily dose of 1.5 mg/kg could we improve his general condition. After two weeks of prednisolone therapy, his laboratory findings were also improved; CRP 4.2 mg/dl, Leukocyte of 10.0 GIGA/L and LDH of 252 U/L. We continued the steroid therapy for overall 6 months with stepwise reduction of the dose until the maintenance dose of 7.5 mg per day.
The research related to human use has been complied with all the relevant national regulations, institutional policies and in accordance the tenets of the Helsinki Declaration, and has been approved by the authors' institutional review board or equivalent committee.
Informed consent has been obtained from all individuals included in this study.