Diagnosis of Tuberculosis in a Case of Chronic Urticaria following Omalizumab Therapy

Abstract

In Italy, tuberculosis (TB) incidence in the last decade has remained constant at under 10 cases/100,000 inhabitants. In the Philippines, TB annual incidence is greater than 500 cases/100,000 inhabitants. Omalizumab is a humanized anti-IgE monoclonal antibody approved for the treatment of chronic spontaneous urticaria. We report the case of a 32-year-old Filipino woman who suffered from chronic urticaria, treated with topic steroids since June 2022 and systemic steroids for 2 weeks. In November 2022, she started omalizumab therapy at a monthly dose of 300 mg; she was not screened for TB infection. In the same month, a left laterocervical lymphadenopathy arose, which worsened in February 2023 (diameter: 3 cm). The patient recovered in April 2023 in INMI "Lazzaro Spallanzani" in Rome for suspected TB. Chest CT showed a "tree in bud" pattern at the upper-right pulmonary lobe. The patient tested positive for lymph node biopsy molecular tuberculosis. The patient started standard antituberculosis therapy. She discontinued omalizumab. To our knowledge, this is the second diagnosed TB case during omalizumab treatment, which suggests that attention should be paid to the known risk of TB during biotechnological treatments. Even if current guidelines do not recommend screening for TB before starting anti-IgE therapy, further data should be sought to assess the relationship between omalizumab treatment and active TB. Our experience suggests that screening for TB should be carried out in patients from highly tuberculosis-endemic countries before starting omalizumab therapy.

Keywords: biotechnological treatments; omalizumab; screening; tuberculosis.

Figure 1

Computed tomography showing a “Tree in bud” (arrow) pattern at the upper-right pulmonary lobe ((upper): coronal-enhanced CT reconstruction, (lower): axial-enhanced CT reconstruction).

Figure 1

Computed tomography showing a “Tree in bud” (arrow) pattern at the upper-right pulmonary lobe ((upper): coronal-enhanced CT reconstruction, (lower): axial-enhanced CT reconstruction).

Figure 2

Computed tomography of the cervical region: Coronal-enhanced CT reconstruction shows a inhomogeneous node at the 3rd level of the neck on the left side, with a peripheral enhancement and a colliquative-necrotic center (arrow).

Figure 3

The pathological aspect of the biopsied later cervical lymphonode: granuloma with central eosinophilic necrosis (blue arrow) surrounded by epithelioid macrophages with pale eosinophilic cytoplasm (arrowhead) and peripheral lymphoctes (green arrow).