Laryngeal tuberculosis in patients treated with adalimumab: a casual or causal connection?

Abstract

This article presents two consecutive cases of laryngeal tuberculosis in patients treated with a specific anti-tumour necrosis factor-alpha (adalimumab), with a focus on their diagnostic process and therapeutic management. Both patients presented with aspecific chronic laryngeal symptoms that had been worsening for a few months in one case and for almost 1 year in the other one. They were both studied with fibreoptic laryngoscopy and contrast-enhanced CT and MRI scans. In both cases, the laryngeal biopsy proved negative to Ziehl-Neelsen test, while positive to Koch's bacillus sensitive to rifampicin at PCR test. Both patients completely responded to standard antitubercular antibiotic therapy with rifampicin, isoniazid, pyrazinamide and etambutol protocol.In the differential diagnosis of such patients, laryngeal tuberculosis should be considered due to the reasonable linkage between the immunosuppressant therapy with adalimumab and the tuberculosis infection/reactivation.

Keywords: Drugs and medicines; Ear, nose and throat; Ear, nose and throat/otolaryngology; Infections.

Figure 1

(A, B) Fibereoptic endoscopic appearance of case #1 at time of ear, nose and throat evaluation. Notice the ulcerated and granulomatous aspect of the epiglottis, aryepiglottic folds and arytenoids. These structures appear enlarged and swollen.

Figure 2

Contrast-enhanced CT of the neck from case 1. Axial view showing enhancing irregular tissue affecting both vocal folds (A) and the supraglottis (B), without relevant reduction of the airway lumen. Multiple enlarged fusiform lymph nodes are present at both cervical sides. (C) Multiple bilateral pulmonary micronodules with typical miliariform spreading can be seen. No cavitated lesions are present.

Figure 3

Follow-up fibreoptic image after 1 month of antitubercular medical therapy from case 1 showing improvement of the patient’s condition.

Figure 4

Endoscopic and radiological appearance of the larynx from case 2. (A) A swollen aspect of the epiglottis and the aryepiglottic folds and arytenoids is visible on fibreoptic examination. (B) Contrast-enhanced CT scan of the neck showing vivid contrast enhancement of the base of the tongue, lingual surface of the epiglottis and right aryepiglottic region.