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Abstract

Background
Latent tuberculosis infection (LTBI) reactivation is a well-known risk associated with immunosuppressive therapies employed in the treatment of rheumatoid arthritis (RA). Tofacitinib, an approved medication for RA that inhibits Janus kinases, has been associated with an elevated risk of TB reactivation. However, diagnosing TB in RA patients can be challenging due to the atypical presentation of the disease in this population.

Case report
In this report, we present the case of a 54-year-old male with a history of RA who presented with symptoms of productive cough, fever, and night sweats. The patient had been receiving sulfasalazine, methotrexate, folic acid, and prednisolone for RA, but due to disease progression, tofacitinib was initiated six weeks prior. Upon examination, the patient displayed respiratory distress and bilateral lung crepitations. Initial treatment with broad-spectrum antibiotics for suspected community-acquired pneumonia proved ineffective, and a chest X-ray revealed bilateral infiltrates in the upper lobes. The patient disclosed a history of previously treated TB infection twelve years ago. Subsequent investigations confirmed reactivation of LTBI, supported by positive results from the Mantoux test and interferon-gamma release assay (IGRA). Tofacitinib and methotrexate were discontinued, and the patient was initiated on the standard four-drug anti-TB therapy. However, the patient's RA symptoms worsened, necessitating the reintroduction of methotrexate at a reduced dosage and the addition of hydroxychloroquine to the treatment regimen. The patient tolerated the TB therapy well and experienced an improvement in RA symptoms with the combination therapy.

Conclusion
This case underscores the significance of considering the risk of LTBI reactivation in RA patients receiving tofacitinib therapy or any other immunosuppressive treatment. Healthcare providers should maintain a high level of suspicion for TB in RA patients with a history of latent TB infection, particularly in regions where TB is prevalent. Additionally, alternative treatment options should be considered to balance the management of RA and the risk of infectious complications. Rapid diagnosis and treatment of active TB are crucial to prevent complications. A multidisciplinary approach involving rheumatologists and pulmonologists is essential for the optimal management of these patients.

Publication Type:	Article
Additional Information:	© 2023 The Author(s). Published by Elsevier B.V. on behalf of Prof. PK Surendran Memorial Education Foundation. This is an open access article distributed under the terms of the Creative Commons CC-BY license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Publisher Keywords:	Tofacitinib, Rheumatoid arthritis, Tuberculosis, Reactivation, Immunosuppression
Subjects:	R Medicine > RA Public aspects of medicine > RA0421 Public health. Hygiene. Preventive Medicine
Departments:	School of Health & Medical Sciences School of Health & Medical Sciences > Department of Allied Health
SWORD Depositor:	Symplectic Administrator

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