关键词: 脊柱炎,强直性, 肿瘤坏死因子类, 拮抗剂, 抗体,单克隆, 机会致病菌感染, 结核, 总结性报告(主题)

Abstract:

Objective To explore the clinical characteristics, main points of diagnosis and treatment, and treatment outcomes of disseminated tuberculosis induced by the application of adalimumab in the treatment of ankylosing spondylitis. Methods The clinical data, diagnosis and treatment, and follow-up of one patient with disseminated tuberculosis induced by the application of adalimumab in the treatment of ankylosing spondylitis who admitted to Fuzhou Pulmonary Hospital of Fujian Province on June 10, 2019 were retrospectively analyzed, and then literature review was performed. The PubMed database was searched with “adalimumab” and “disseminated tuberculosis” as the key words, and the Chinese literature was searched from Wanfang and China National Knowledge Infrastructure database with the key words of “adalimumab” and “disseminated tuberculosis”. The search period was up to September 2019. After screening and eliminating, a total of 34 related literatures were obtained, including 0 in Chinese and 34 in English. The repeated literatures were deleted, and the reports of disseminated tuberculosis caused by tumor necrosis factor α (TNF-α) other than adalimumab and other disseminated diseases caused by TNF-α were excluded. A total of 8 literatures with detailed case data were selected and a total of 8 patients were obtained. Afterwards, combined with the patients collected in this study, the clinical characteristics, diagnosis and treatment of these 9 cases were analyzed. Results A 28-year-old male received adalimumab treatment due to ankylosing spondylitis, and cough, shortness of breath, abdominal distension and fever occurred 2 months after treatment. After admission, patient was diagnosed with “disseminated tuberculosis (double lung, right bronchus, chest cavity, abdominal cavity, pericardium, mediastinal lymph node, supraclavicular lymph node, abdominal lymph node, pelvic lymph node, and spleen)” by chest CT, pleural biopsy and bronchoscopy. Symptoms of patient was improved after treatment with “3H-R-Z-E/9H-R-E” regimen, supplemented by local inhalation of isoniazid by bronchial nebulizer, and anti-tuberculous drug treatment. At the 5th month of treatment, CT reexamination suggested that lung lesions were reduced, partial lymph node enlargement in the mediastinum was smaller, thickened bronchial tube wall was thinner, lumen was more unobtrusive, and effusion in chest and abdominal cavity was significantly absorbed. As of December 2019, patient was still on regular anti-tuberculous drug treatment. After literature search, 8 patients were obtained, and there were 9 patients after adding this case, including 3 males and 6 females; they aged 9 to 75 years, with an average age of (50.44±25.19) years. Among these 9 patients, 5 cases were negative for tuberculous screening test before beginning treatment with adalimumab, 1 case had a previous history of anti-tuberculous treatment, and 1 case had a history of prophylactic anti-tuberculous treatment, and 3 cases had a history of close contact with tuberculous patients. Five patients had a good outcome after a clear diagnosis and anti-tuberculosis treatment. The outcome was poor in 3 cases, of which 1 continued to progress with gastrointestinal bleeding; 1 continued to develop intracranial lesions; 1 developed acute respiratory distress syndrome and eventually died. One patient had unknown outcome. Conclusion Adalimumab can cause disseminated tuberculosis. Patients who are going to receive adalimumab treatment should be screened for tuberculosis before administration. During treatment, they should be alert to the conversion of latent tuberculosis infection to active tuberculosis and new tuberculosis infection. Discontinuation of adalimumab and timely anti-tuberculosis treatment are the keys to a good prognosis.

Key words: Spondylitis,ankylosing, Tumor necrosis factors, Antistatic agents, Antibodies,monoclonal, Opportunistic infections, Tuberculosis, Consensus development conferences as topic