Tuberculous monoarthritis in a rituximab-treated patient with rheumatoid arthritis: diagnostic and therapeutic challenges in a tuberculosis-endemic region.

A woman in her 60s with seropositive rheumatoid arthritis developed tuberculous arthritis of the wrist following rituximab therapy, despite negative latent tuberculosis (TB) screening. Although rituximab is considered safer than anti-TNF agents in terms of TB risk, this case highlights a rare yet serious complication. Diagnosis was confirmed via synovial fluid analysis after persistent monarthritis unresponsive to standard RA therapy. Management was complicated by drug-induced liver injury and ototoxicity, leading to multiple modifications of anti-tubercular therapy. The therapeutic dilemma centred on balancing effective TB treatment with drug tolerability, necessitating a cautious, stepwise reintroduction of first-line agents. Despite these challenges, the patient achieved full recovery and later resumed low-dose methotrexate for RA. This case underscores the importance of considering TB even with negative screening and demonstrates that individualised therapy can overcome complex treatment barriers in immunosuppressed patients in TB-endemic settings.