Psoriasis, Anti-Tumor Necrosis Factor Therapy, and Tuberculosis: Report of Three Challenging Cases and Literature Review

Abstract

IntroductionThe era of biologic therapies has provided new options for the treatment of chronic plaque psoriasis. However, safety concerns have led to intensive screening and monitoring of patients receiving anti-tumor necrosis factor alpha (anti-TNF-alpha) agents.MethodsThe authors describe the cases of three patients with moderate to severe psoriasis treated with anti-TNF agents, with challenging diagnostic and treatment aspects regarding tuberculosis (TB) infection, a serious adverse event associated with this type of treatment. The cases are discussed in the context of a comprehensive literature review describing the risk of TB associated with the use of TNF inhibitors. A critical review of the clinical trials that have tested the safety of these agents is also presented.ResultsOne patient, who tested negatively for latent TB infection (LTBI) during screening, developed active TB under adalimumab therapy. For two other patients the diagnosis and management of LTBI in relation to anti-TNF therapy represented a challenge. Although clinical trials involving the use of anti-TNF therapy for psoriasis haven’t demonstrated a high TB incidence, active TB is continuously reported in association with this treatment.ConclusionsFindings from clinical practice and the scientific literature indicate that anti-TNF therapies are associated with an increased risk of TB, and close monitoring of patients is needed.

Relative risk of tuberculosis in patients with rheumatic diseases managed with anti-tumour necrosis factor-alpha therapy: A nationwide cohort study

“…The former was consistent with the systematic meta‐analyses comprising either randomized clinical trials or registries/cohort studies of anti‐TNF‐α drugs that reported significant TB risk increment in RA patients . On the other hand, detection of increased significant TB risk for PsA, albeit with a quite broad confidence interval, could be regarded as the first in the literature except few suspected case reports . Furthermore, a small cohort of PsA patients with latent TB infection reported no development of TB during 2‐year follow‐up .…”

“…13,30 On the other hand, detection of increased significant TB risk for PsA, albeit with a quite broad confidence interval, could be regarded as the first in the literature except few suspected case reports. 34 Furthermore, a small cohort of PsA patients with latent TB infection reported no development of TB during 2-year follow-up. 35 Considering probable overdiagnosis of latent TB infection and consequent prophylaxis due to overestimation of tuberculin skin test values among psoriasis patients, 36,37 the risk observed in our PsA patients might be raised more than predicted.…”

Risk of Reactivation of Latent Tuberculosis in Psoriasis Patients on Biologic Therapies: A Retrospective Cohort from a Tertiary Care Centre in Northern Italy

“…( 3 , 4 ). Over the past 20 years, therapy with biologics has resulted in significant responses, but immune depression remains a challenge ( 5 ).…”

Miliary tuberculosis in a paediatric patient with psoriasis

“…Cases of disseminated or military tuberculosis, a disease caused by the acid-fast bacillus M. tuberculosis , secondary to TNF-α inhibitors are becoming more commonplace, though they remain rare in paediatric patients. 4–8 However, the increasing use of immunomodulatory medications such as TNF-α inhibitors is increasing the risk of presentation. Testing for latent tuberculosis remains imperative prior to initiating immunomodulatory therapy, but it is unable to prevent all infections.…”