S4916 Biologic Induction Therapy in Hospitalized Ulcerative Colitis With Latent Tuberculosis: A Case Series Emphasizing Individualized Care

Introduction: Initiating biologic therapy in Ulcerative Colitis (UC) and latent tuberculosis infection (LTBI) increases risk of LTBI reactivation. This poses a clinical challenge, particularly when inpatient, where urgent induction is often necessary. We present 2 cases with UC flares and concurrent LTBI requiring biologic therapy following steroid-refractory disease. Case Description/Methods: Case 1: A 24-year-old woman with UC with a 2-month history of >15 bloody stools daily. LTBI was diagnosed during outpatient pre-biologic screening, and rifampin was started 1 month prior to admission per infectious disease (ID) recommendation. On admission, she was hypotensive and tachycardic with C-reactive protein (CRP) of 1.9 mg/dL. Computed tomography revealed proctosigmoiditis, and colonoscopy demonstrated Mayo 2 (moderate) pancolitis with chronic active colitis and negative cytomegalovirus staining. After failing a 72-hour intravenous (IV) steroid trial, vedolizumab was initiated with ID guidance. Her symptoms and CRP improved, and she was discharged on a steroid taper with plans for outpatient vedolizumab maintenance. Case 2: A 48-year-old man with UC presented with 8 days of >10 bloody stools daily with abdominal pain and intermittent fevers. He was tachycardic with elevated CRP (13.4 mg/dL). Computed tomography showed pancolitis and colonoscopy revealed Mayo 3 (severe) colitis in the right colon with Mayo 2 (moderate) colitis in the left. After failing a 72-hour IV steroid trial, pre-biologic screening revealed LTBI. A multidisciplinary team initiated infliximab alongside isoniazid and B6. He showed rapid clinical improvement and was discharged with outpatient infliximab therapy. At 1 and 4 months, both patients were without clinical or radiological evidence of active tuberculosis. Discussion: Although infliximab or cyclosporine are the standard treatment for hospitalized patients with acute severe UC unresponsive to IV steroids, the presence of LTBI complicates decision-making. In case 1, vedolizumab was chosen for its gut-specific mechanism and low reactivation risk when slower onset of action was feasible. In case 2, infliximab was chosen for rapid effect in a severe flare after weighing LTBI reactivation risk and the patient’s refusal of surgery. These cases underscore the importance of balancing severity, onset of action, risk of disease progression, and reactivation of LTBI. While completion of LTBI therapy is ideal before biologic initiation, urgent clinical needs may justify after 3 weeks—or even concurrently—with ID involvement.