Infliximab use for corticosteroid-resistant tuberculosis immune reconstitution inflammatory syndrome (TB-IRIS) in an imm
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CASE REPORT
Infliximab use for corticosteroid‑resistant tuberculosis immune reconstitution inflammatory syndrome (TB‑IRIS) in an immunocompetent patient Deborah Eshagh1 · Khadija Benali2 · Antoine Dossier1 · Marie Paule Chauveheid1 · Diane Rouzaud1 · Tiphaine Goulenok1 · Thomas Papo1,3 · Karim Sacre1,3 Received: 28 April 2020 / Accepted: 22 June 2020 © Springer-Verlag GmbH Germany, part of Springer Nature 2020
Abstract In non-human immunodeficiency virus (HIV)-infected patients, tuberculosis (TB) immune reconstitution inflammatory syndrome (IRIS) is unusual. The management of corticosteroids-refractory IRIS is unclear. We report on infliximab efficacy for treatment of corticosteroid-resistant TB-IRIS occurring in an immunocompetent patient. Keywords Tuberculosis · Immune reconstitution inflammatory syndrome · Infliximab
Introduction
Case report
Immune reconstitution inflammatory syndrome (IRIS) is an aberrant inflammatory disorder with paradoxical worsening of preexisting treated infections. IRIS mostly occurs in patients infected with human immunodeficiency virus (HIV) after antiretroviral therapy initiation and corticosteroids are the cornerstone of IRIS therapy [1]. Corticosteroid-resistant mycobacterial IRIS is very rare, especially in immunocompetent patients. Here, we report on the efficient use of infliximab for steroid-unresponsive TB-IRIS with no immunocompromised condition.
A 55-year-old woman was admitted to our department in October 2018 for intermittent fever and weight loss for several weeks. The patient was born in Morocco and had been living in France for the last 28 years. Her medical history was unremarkable. At admission, the body temperature was 37.1 °C. Physical examination showed multiple enlarged cervical lymph nodes, but was otherwise normal. Complete blood count and serum levels of creatinine, calcium and transaminase were normal. C-reactive protein (CRP) level was 7 mg/L (Fig. 1a). Blood cultures and HIV serology were negative. QuantiFERON-TB Gold in-Tube test yielded a positive result. Lymphocytes counts in blood were normal (1780 cells/mm3) including 1340/mm3 (75%) CD3+, 960/ mm3 (56%) CD3+CD4+, 290/mm3 (17%) CD3+CD8+, 40/ mm3 (2%) CD3+CD16+CD56+, 240/mm3 (14%) CD19+ and 160/mm3 (9%) C D3−CD16+CD56+ cells. Serum levels of C3, C4, IgG, IgM and IgA were normal. 18-Fluorodeoxyglucose /positron emission tomography (FGD/PET) revealed an intense FDG uptake of multiple (right cervical, right supraclavicular, right axillary, mediastinal, aortic and iliac) lymph nodes and lytic bone (femur, right ilium, right sacrum, left radius and right tibia) lesions (Fig. 1b). A right supraclavicular lymph node biopsy was eventually performed and histopathological examination showed numerous epithelioid and multinucleated giant cells necrotizing granuloma. Grocott’s methenamine silver and Ziehl–Neelsen stains were negative. Lymph node culture
* Karim Sacre [email protected] 1
Assistance Publique Hôpitaux de Paris, Département de Médecine Interne, Hôpital Bichat‑Claude Bernard, Université
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