P0332 Unmasking a Hidden Foe: Miliary Tuberculosis in a Young Crohn’s Patient during Anti-TNF Therapy

Abstract Background Tumor necrosis factor alpha (TNF-α) inhibitors, significantly improve outcomes in moderate-to-severe Crohn’s disease (CD) but increase susceptibility to tuberculosis (TB). Screening before treatment initiation reduces risks, yet TB may still develop during therapy. Herein, we report a case illustrating the challenges of managing severe Crohn’s disease on biologic therapy complicated by TB infection and paradoxical autoimmune phenomena. Methods An 24 year old female patient diagnosed with Crohn’s disease at age 18 (Montreal classification A1, L3+L4, B1) was treated with corticosteroids and azathioprine, then escalated to infliximab due to inadequate disease control. Baseline interferon-gamma release assay (IGRA) and chest radiography were negative. After a clinical flare, the infliximab dose was intensified. Shortly thereafter, a repeat IGRA converted to positive, indicating latent TB infection. Isoniazid prophylaxis was initiated while infliximab therapy continued under close monitoring. Results Under anti TNF- α agents, the patient achieved clinical remission of Crohn’s disease; however, she subsequently developed severe paradoxical psoriasis and alopecia areata, presumed to represent immune-mediated complications of anti-TNF therapy, for which methotrexate was initiated. One year later, she presented with ascites, pleural effusion, and low-grade fever in the emergency room. Cross-sectional imaging revealed peritoneal and pleural lesions suspicious for TB, although serial microbiological cultures remained negative. An exploratory laparotomy with biopsy demonstrated caseating granulomas in the peritoneum, confirming peritoneal tuberculosis, which subsequently progressed to miliary TB. Infliximab and methotrexate were discontinued, and a 12-month course of anti-tuberculous therapy was initiated. Conclusion This case highlights the importance of vigilant TB screening and continued monitoring in inflammatory bowel disease patients receiving anti-TNF therapy, even after negative baseline screening and prophylaxis. It also underscores the need to recognize and manage paradoxical immune-related adverse effects. Multidisciplinary monitoring is essential for early detection of TB. Reference: 1. G.R. D’Haens, et al.Gut, 70 (2021), pp. 1396-1405 Conflict of interest: Dr. Mare, Ruxandra: No conflict of interest Pienar, Corina: none Taban, Sorina: none Popescu, Alina: none Sirli, Roxana: none Goldiș, Adrian Eugen: none