Fulminant Pulmonary Tuberculosis by Infliximab in Patient withRheumatoid Arthritis

A 72-year-old Japanese woman who had been suffering from rheumatoid arthritis for five years started treatment with infliximab. The screening of a chest X-ray before initiating infliximab treatment showed no abnormal shadows. After a month of infliximab, she was admitted to the emergency hospital with a half-month history of a fever, fatigue, dyspnea, and cough. She was diagnosed with tuberculosis from a culture smear and referred to our hospital. The chest images showed a bilateral massive cavity and infiltration. Despite the administration of an anti-tuberculous agent, the cavity and infiltration were enlarged on a chest X-ray and the patient died due to respiratory failure. Cases of tuberculosis resulting in death after a short duration of infliximab treatment have been rarely reported. We speculate that chest CT and the interferon-gamma release assay (IGRA) for tuberculosis screening should be evaluated before starting infliximab treatment, and preventive administration of isoniazid should be considered with consultation with a pulmonologist.