Difficult diagnosis of infliximab-related miliary tuberculosis.

The use of Infliximab in the treatment of patients with rheumatoid diseases unresponsive to conventional therapies has been reported to be complicated by opportunistic infections. We report the case of a 56-yr old female rheumatoid arthritis patient complaining of fever and respiratory symptoms 9 months after commencing Infliximab, who received no ethiologic diagnosis for the six months before admission. Her medical history was remarkable for pleural TB at the age of 11 years and for a 12-year history of severe RA unresponsive to both steroidal and nonsteroidal anti-inflammatory drugs. She had commende Infliximab 15 months prior to admission. Tuberculosis was suspected upon chest radiographic pictures and empirical treatment for miliary tuberculosis instated in the wake of microbiological confirmation. The case typifies the difficulties of diagnosing miliary tuberculosis in the immunocompromised as well as in the immunocompetent patient. In miliary TB, the intensity of the elimination of TB bacilli in spontaneously produced sputum samples is reportedly very low. Blood cultures have been found the most sensitive tool for the diagnosis of TB in immunocompromised subjects, where pulmonary TB may present in the absence of radiological findings and miliary TB is frequently associated with higher degrees of immunodeficiency. Blood cultures, together with CT scans, may provide highly indicative results and help avoiding more aggressive interventions.