İZONİAZİD PROFLAKSİSİ ALTINDA TNF-α BLOKER TEDAVİ UYGULANMASINA BAĞLI GELİŞEN TÜBERKÜLOZ PLÖREZİ OLGUSU

Anti-TNF-α antikor tedavisi için günümüzde onaylanmış endikasyonlar artmaktadır. Bu tedavinin yan etkilerinden biri de latent tüberküloz enfeksiyonun reaktivasyonudur. Olgumuz 49 yaşında bayan hasta 15 yıldır ankilozan spondilit tedavisi görmekte olup. 2003 yılından bu yana TNF-α bloker (infliximab) tedavisi kullanmaktaydı. 2003 yılındaki tüberkülin deri testi ölçümünün 11 mm olması nedeniyle 9 ay süreyle izoniazid proflaksisi almıştı. Beş yıl sonra konsulte edilen hastada plöretik göğüs ağrısı mevcuttu. Akciğer grafisinde parankim normal olup solda plevral efüzyon mevcuttu. Torasentezle alınan eksuda niteliğindeki sıvıda adenozin deaminaz düzeyi 125 U/L olarak saptandı. Başlanan dörtlü anti tüberküloz tedavi sonrası birinci ayda çekilen kontrol toraks BT'de plevral efüzyonda tam düzelme izlendi. Tedaviye yanÝt alÝnan hasta TNF-α bloker tedavisine sekonder gelişen tüberküloz plörezi olarak tanı aldı. İzoniazid proflaksisi almış olmasına rağmen tüberküloz plörezi gelişen olgumuzu literatürlerde ender rastlanması ve izoniazid proflaksisi alan adenohastalarda da tüberküloz reaktivasyonu olabileceğini ve bunun plevral efüzyon şeklinde ortaya çıkabileceğini göstermesi bakımından sunmayı uygun bulduk.

Anahtar Kelimeler:

Anti-TNF-a, latent tüberküloz, adenozin deaminaz, izoniazi

A CASE OF TUBERCULOSIS PLEURITIS ASSOCIATED WITH THE TREATMENT OF TNF-α BLOCKER UNDER ISONIAZIDE PROPHYLAXIS

Approved indicat ions for treatment of anti-TNF-α antibody are growing nowadays. One of the side effects of this treatment is reactivation of latent tuberculosis infection. Our female patient aged 49 has received the treatment due to ankylosing spondilitis for 15 years. She has also received the treatment of TNF-α bloker (infliximab) since 2003. Our case received the isoniazide prophylaxis treatment in 9 month-term because of the fact that her PPD measurement was 11 mm in the year of 2003. Five years later the patient had consultation and had pleuritic chest pain. Pleural effusion was ascertained on the left although there was no paranchyma infiltration in the chest radiography. In exudation which was taken by thoracentesis, adenosine deaminase degree coming from the material was ended up as 125 U/L. Absolute improvement on the pleural effusion was followed in control thorax BT which was taken in a month after the treatment of quartiles anti tuberculosisto. The patient who gave good response to treatment was diagnosed as tuberculosis pleurisy which was secondary to TNF-α blocker treatment. We have approved to present our case having developed tuberculosis pleusiry despite taking isoniazide prophylaxis because it has a rare occurrence in literature and shows that tuberculosis reactivation could be seen in patients taking isoniazide prophylaxis and could manifest it self as pleural effusion.

Keywords:

Anti-TNF-a, latent tuberculosis, adenosine deaminase, isoniazide,

PDF

___

1. Botsios C. Safety of tumour necrosis factor and interleukin-1 blocking agents in rheumatic diseases. Autoimmunity Reviews 2005; 4: 162-70.
2. Crum NF, Lederman ER, Wallace MR. Infections associated with tumor necrosis factor-a antagonists. Medicine 2005; 84: 291-302.
3. Mutlu G, Mutlu E, Bellmeyer A, Rubinstein I. Pulmonary Adverse Events of Anti-Tumor Necrosis Factor-a Antibody Therapy. The American Journal of Medicine, Volume 119, Issue 8, Pages 639-646.
4. Amiri P, Locksley RM, Parslow TG, et al. Tumour necrosis factor alpha restores granulomas and induces parasite egg-laying in schistosome-infected SCID mice. Nature 1992; 356: 604-7.
5. Piguet PF, Collart MA, Grau GE, Sappino AP, Vassalli P. Requirement of tumour necrosis factor for development of silica-induced pulmonary fibrosis. Nature 1990; 344: 245-7.
6. Miyazaki Y, Araki K, Vesin C, et al. Expression of a tumor necrosis factor-alpha transgene in murine lung causes lymphocytic and fibrosing alveolitis. A mouse model of progressive pulmonary fibrosis. J Clin Invest 1995; 96: 250-9.
7. Utz JP, Limper AH, Kalra S, et al. Etanercept for the treatment of stage II and III progressive pulmonary sarcoidosis. Chest 2003; 124: 177-85.
8. Stone JH, Uhlfelder ML, Hellmann DB, Crook S, Bedocs NM, Hoffman GS. Etanercept combined with conventional treatment in Wegener’s granulomatosis: a six-month open-label trial to evaluate safety. Arthritis Rheum 2001; 44: 1149-54
9. The Wegener’s Granulomatosis Etanercept Trial (WGET) Research Group. Etanercept plus standard therapy for Wegener’s granulomatosis. N Engl J Med 2005; 352: 351-61.
10. Keane J, Gershon SK, Braun MM. Tuberculosis and treatment with infliximab. N Engl J Med 2002; 346: 623-6.
11. Keane J, Gershon S, Wise RP, et al. Tuberculosis associated with infliximab, a tumor necrosis factor alpha-neutralizing agent. N Engl J Med 2001; 345: 1098-104.
12. Wallis RS, Broder MS, Wong JY, Hanson ME, Beenhouwer DO. Granulomatous infectious diseases associated with tumor necrosis factor antagonists. Clin Infect Dis 2004; 38: 1261-5.
13. Ako¤lu S, Babayi¤it C, Karazincir S, Balc› A, Hanta ‹. Tümör nekroz faktörü-_ antagonisti kullan›m› sonras› geliflen tüberküloz plörezi: Olgu sunumu. Tüberküloz ve Toraks Dergisi 2008; 56: 448-52.
14. Rosenow E, Strimlan CV, Muhm JR, et al. Pleuropulmonary manifestations of ankylosing spondylitis. Mayo Clin Proc 1977; 52: 641-9.