Reactivation of Spinal Tuberculosis in a Patient with Rheumatoid Arthritis on Low-dose Methotrexate

Narjust Duma MD^1, , Jaime Mittal MD¹ and Sobia Nizami¹

¹Rutgers-New Jersey Medical School, Newark, NJ, United States

Cite this paper

Narjust Duma MD, Jaime Mittal MD and Sobia Nizami. Reactivation of Spinal Tuberculosis in a Patient with Rheumatoid Arthritis on Low-dose Methotrexate. American Journal of Medical Case Reports. 2015; 3(5):137-140. doi: 10.12691/AJMCR-3-5-5

Abstract

42 year old Hispanic woman with rheumatoid arthritis who has been taking methotrexate for 24 weeks was admitted for severe, sharp lumbar back pain for 3 weeks. The pain radiated to both legs, worsened with walking or standing and improved at rest. It was accompanied by low grade fevers, anorexia and generalized fatigue. The patient denied cough or shortness of breath. MRI of the spine showed an L4 pathologic deformity with abnormal marrow infiltration and a ring-enhancing lesion within the left psoas muscle suspicious for abscess. CT-guided biopsy of the psoas showed necrotic debris and neutrophilic infiltrates. PPD test was reported negative. Bacterial and fungal cultures were negative after 5 days. She was discharged with an empiric 30-day regimen of intravenous ceftriaxone and oral linezolid due to high suspicion for a bacterial etiology. Twenty-six days later, the patient returned due to worsening of her back pain, she was unable to ambulate, and had a 15 pound interval weight loss. Previous biopsy cultures were positive for acid-fast bacilli and repeat MRI showed pathologic collapse of L4 with a retropulsive fracture, superimposed phlegmons bilaterally, severe spinal stenosis, and compression of the cauda equina. Three sputum specimens for AFB smears were negative. The patient recalled having had a BCG vaccine and a negative PPD in 1995; she denied exposure to TB or international travel for the past 21 years. The patient was placed on a 6 months regimen of isoniazid, rifampin, pyrazinamide, ethambutol, and pyridoxine. Two months after her presentation, she required an L4 corpectomy with a vertebral replacement cage, an L2-L4 laminectomy, and L3-L5 fusion due severe back pain and spine instability.

Keywords

spinal tuberculosis, methotrexate, rheumatoid arthritis, Pott ’s diseas

Copyright

This work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

References

[1]	Scott DL, Wolfe F, Huizinga TW. Rheumatoid arthritis. Lancet. 2010; 376(9746):1094-108.
[2]	Wolfe F, Michaud K, Anderson J, Urbansky K. Tuberculosis infection in patients with rheumatoid arthritis and the effect of infliximab therapy. Arthritis & Rheumatism. 2004; 50(2):372-9.
[3]	Keane J, Bresnihan B. Tuberculosis reactivation during immunosuppressive therapy in rheumatic diseases: diagnostic and therapeutic strategies. Current opinion in rheumatology. 2008; 20(4):443-9.
[4]	Binymin K, Cooper RG. Late reactivation of spinal tuberculosis by low-dose methotrexate therapy in a patient with rheumatoid arthritis. Rheumatology (Oxford, England). 2001; 40(3):341-2.
[5]	Carmona, Loreto, et al. "Increased risk of tuberculosis in patients with rheumatoid arthritis." The Journal of rheumatology 30.7 (2003): 1436-1439.
[6]	Singh JA, Furst DE, Bharat A, Curtis JR, Kavanaugh AF, Kremer JM, et al. 2012 Update of the 2008 American College of Rheumatology recommendations for the use of disease‐modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis care & research. 2012; 64(5):625-39.
[7]	Doherty SD, Van Voorhees A, Lebwohl MG, Korman NJ, Young MS, Hsu S, et al. National Psoriasis Foundation consensus statement on screening for latent tuberculosis infection in patients with psoriasis treated with systemic and biologic agents. Journal of the American Academy of Dermatology. 2008; 59(2): 209-17.
[8]	Lamb SR. Methotrexate and reactivation tuberculosis. Journal of the American Academy of Dermatology. 2004; 51(3): 481-2.
[9]	Neurath MF, Hildner K, Becker C, Schlaak JF, Barbulescu K, Germann T, et al. Methotrexate specifically modulates cytokine production by T cells and macrophages in murine collagen-induced arthritis (CIA): a mechanism for methotrexate-mediated immunosuppression. Clinical and experimental immunology. 1999; 115(1): 42-55.
[10]	Mor A, Bingham CO, Kishimoto M, Izmirly PM, Greenberg JD, Reddy S, et al. Methotrexate combined with isoniazid treatment for latent tuberculosis is well tolerated in patients with rheumatoid arthritis: experience from an urban arthritis clinic. Annals of the Rheumatic Diseases. 2008; 67(4): 462-5.
[11]	Aletaha D, Smolen JS. The rheumatoid arthritis patient in the clinic: comparing more than 1,300 consecutive DMARD courses. Rheumatology (Oxford) 2002; 41: 1367-74.
[12]	Luis M, Pacheco-Tena C, Cazarin-Barrientos J, Lino-Perez L, Goycochea MV, Vazquez-Mellado J, et al. Comparison of two schedules for administering oral low-dose methotrexate (weekly versus every-other-week) in patients with rheumatoid arthritis in remission: a twenty-four week, single blind, randomized study. Arthritis Rheum 1999; 42: 2160-5.
[13]	Visser K, Katchamart W, Loza E, Martinez-Lopez JA, Salliot C, Trudeau J, et al. Multinational evidence-based recommendations for the use of methotrexate in rheumatic disorders with a focus on rheumatoid arthritis: integrating systematic literature research and expert opinion of a broad international panel of rheumatologists in the 3E Initiative. Ann Rheum Dis 2009; 68: 1086-93.
[14]	Zorlu M, Kiskac M, Karatoprak C, Cakirca M, Yavuz E, Cetin G, et al. Pott's disease and hypercalcemia in a patient with rheumatoid arthritis receiving methotrexate monotherapy. Indian journal of pharmacology. 2013; 45(6):631-3.
[15]	Park JS, Jung ES, Choi W, Park SY, Rim MY, Yu I, et al. Mycobacterium intracellulare Pulmonary Disease with Endobronchial Caseation in a Patient Treated with Methotrexate. Tuberculosis and respiratory diseases. 2013; 75(1): 28-31.
[16]	Ben m'rad M, Gherissi D, Mouthon L, Salmon-Ceron D. [Tuberculosis risk among patients with systemic diseases]. Pressemedicale (Paris, France: 1983). 2009; 38(2):274-90.
[17]	Ponce de Leon D, Acevedo-Vasquez E, Alvizuri S, Gutierrez C, Cucho M, Alfaro J, et al. Comparison of an interferon-gamma assay with tuberculin skin testing for detection of tuberculosis (TB) infection in patients with rheumatoid arthritis in a TB-endemic population. The Journal of rheumatology. 2008; 35(5):776-81.
[18]	Turgut M. Spinal tuberculosis (Pott's disease): its clinical presentation, surgical management, and outcome. A survey study on 694 patients. Neurosurg Rev 2001; 24:8.