Pulmonary tuberculosis and tuberculous pleuropericarditis in a patient with pyoderma gangrenosum treated with adalimumab: a case report.

BACKGROUND: Adalimumab is a tumor necrosis factor-α inhibitor, which is associated with an increased risk of tuberculosis. However, evidence regarding tuberculosis development in patients with pyoderma gangrenosum is limited, and simultaneous involvement in lungs, pleura, and pericardium is rare. This report describes a case of pulmonary tuberculosis and tuberculous pleuropericarditis associated with adalimumab administration.

CASE PRESENTATION: The patient was a 59-year-old Filipino female. She began receiving adalimumab to treat pyoderma gangrenosum at the dermatology department of our hospital. The serum interferon-gamma release assay using QuantiFERON test, measured prior to administration, was negative. After five times of administration, she presented with fever, cough, and dyspnea. A chest computed tomography scan showed multiple small nodular shadows in the lung fields, right pleural effusion, and pericardial effusion. The administration of antibiotics and diuretics was ineffective. The QuantiFERON test was repeated, and was positive. The rapid sputum test for tuberculosis antigen was positive, and Mycobacterium tuberculosis was subsequently cultured 23 days later. Thus, she was diagnosed with pulmonary tuberculosis. Standard treatment with a combination of four antituberculous drugs was started, but drug susceptibility testing revealed resistance to isoniazid, so isoniazid was changed to levofloxacin. After treatment, multiple small nodular shadows in the lung fields disappeared, and the pleural and pericardial effusions completely resolved. Thus, we clinically diagnosed pulmonary tuberculosis with combined tuberculous pleuropericarditis. To the best of our knowledge, there have been no reports of pulmonary tuberculosis and tuberculous pleuropericarditis following adalimumab administration.

CONCLUSION: This case highlights the importance of considering both pulmonary and extrapulmonary tuberculosis as potential complications of adalimumab, even in patients with initially negative interferon-gamma release assay results. Repeat testing may be crucial for early detection, especially in high-risk individuals from endemic areas.