A 17- year- old woman was regularly treated for years with TNF- a- blocker adalimumab based on her refractory SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome. TB- Screening with IGRA (Interferon Gamma Release Assay) before the therapy with TNF- a-blocker tested negative.
Due to increasing dyspnea, somnolence and septic shock, she was treated in the emergency room of a community hospital. Through sputum, blood culture and cerebrospinal puncture, the diagnosis of severe tuberculosis with meningitis and pulmonary infiltrates was rendered. After the diagnosis of tuberculosis, her regular therapy with adalimumab was discontinued. The standard treatment of 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) was initiated.
Five months after the discontinuation of the adalimumab therapy, we observed cerebral lesions in the basal meningeal region and in the follow- up cerebral MRI- Scan (Fig.1 and Fig 2). Due to cerebral progression and consequential tonic- clonic convulsive seizure, the initiation of antiepileptic drugs with levetiracetam has been initiated. Because of the raising intracranial pressure and ventricular distension, a ventriculo- peritoneal shunt was also installed after the first tonic-clonic convulsive seizure.
A neurosurgical intervention was not considered based on location of those cerebral lesions. The oral steroid prednisolone dose was elevated to 80 mg per day. Under the oral steroid therapy clinical conditions improved in patient. Steroid therapy was continued for overall 6 months with stepwise reduction of the dose until the maintenance dose of 7.5 mg per day. The patient still has a slightly vertigo distraction, but she stays employable at a limited level.