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Disseminated Tuberculosis and Lung Cancer Associated With Infliximab Treatment of Rheumatoid Arthritis: Case Report and Review of Literature

Sankaranarayanan, Viji MD*; Krishna, Ganesh MD; Gould, Michael MD, MSc; Chitkara, Rajinder MD, FCCP

doi: 10.1097/01.cpm.0000156636.88068.45
Topics in Pulmonary Medicine
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Tumor necrosis factor (TNF)-α blockers have emerged as valuable tools in the treatment of active rheumatoid arthritis. The increased incidence of reactivated latent mycobacterial infection following institution of infliximab therapy has been reported. However, less is known about the risk of malignancy with use of anti-TNF antibodies. We present a case of disseminated tuberculosis, possible infection with Mycobacterium fortuitum, and lung cancer in association with infliximab therapy in a 55-year-old man with active rheumatoid arthritis who had received previously isoniazid chemoprophylaxis. We review the existing literature on anti-TNF agents and risk of tuberculosis and malignancy.

Biological immunomodulators such as tumor necrosis factor-α (TNF-α) antagonist have revolutionized the treatment of active rheumatoid arthritis. Unfortunately, such therapy may lead to reactivation of fungal and mycobacterial diseases in susceptible hosts. Additionally, their contribution to the development of malignancies is uncertain. This paper describes a case of rheumatoid arthritis complicated by disseminated tuberculosis despite adequate isoniazid nuclear transcription factor κ B chemoprophylaxis and reviews the current understanding of role of anti-TNF-α therapy in reactivation tuberculosis and malignancy.

From the *Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, CA; and †Pulmonary Section, Medical Services, Veterans Affairs Palo Alto Health Care System and Stanford University School of Medicine, Palo Alto, CA.

No financial support was received by any of the authors. Dr. Gould is a recipient of a research career development award from the VA Health Services Research and Development Service. The views expressed in the article are those of the authors and do not necessarily reflect the views of the Department of Veterans Affairs.

Address for correspondence: Viji Sankaranarayanan, MD, Division of Pulmonary and Critical Care Medicine, Southern California Permanente Medical Group, 4647 Zion Ave., San Diego, CA 92120. E-mail: vijisank@gmail.com.

© 2005 Lippincott Williams & Wilkins, Inc.