title: Tuberculosis of the tongue in a patient with rheumatoid arthritis treated with methotrexate and adalimumab.
abstract: In recent years Tumor Necrosis Factor alpha (TNF alfa) inhibitors have been highly effective in treating rheumatoid arthritis (RA). However, patients receiving these inhibitors have an increased risk of developing tuberculosis (TB). We describe a rare case of tuberculosis of the tongue in an RA patient treated with methotrexate (MTX) and the TNF alfa inhibitor adalimumab (ADA) for the previous six years. Pretreatment tuberculin skin test (TST) was negative. The patient was admitted to our division complaining of a sore throat for months. Clinical examination revealed a swollen non-healing ulcer at the base of the tongue, which was suspected to be a squamous cell carcinoma. Histopathological assessment unexpectedly revealed a chronic granulomatous inflammation compatible with tuberculosis. TST was strongly positive and the T Spot TB test was also reactive. MTX and ADA were discontinued and the patient received antituberculous treatment with complete healing of the lesion. After three months our patient had a worsening RA that was treated with MTX and rituximab with no TB related adverse events. This case highlights the importance of considering tuberculosis in the differential diagnosis of ulcerative lesions of the oral cavity, especially in immunocompromised patients treated with TNF alfa inhibitors. Rituximab can be a valid alternative therapy in such patients.
authors: Section of Respiratory Diseases, Department of Surgery and Clinical Medicine, University Federico II, Naples; Unit of Pathology, AORN Ospedali dei Colli, Naples, Italy; Unit of Pathology, AO G. Rummo, Benevento, Italy.
authors: Luca Rosario
authors: LR
authors: Assante
authors: Section of Respiratory Diseases, Department of Surgery and Clinical Medicine, University Federico II, Naples; Unit of Pathology, AORN Ospedali dei Colli, Naples, Italy; Unit of Pathology, AO G. Rummo, Benevento, Italy.
authors: Enrica
authors: E
authors: Barra
authors: Section of Respiratory Diseases, Department of Surgery and Clinical Medicine, University Federico II, Naples; Unit of Pathology, AORN Ospedali dei Colli, Naples, Italy; Unit of Pathology, AO G. Rummo, Benevento, Italy.
authors: Marialuisa
authors: M
authors: Bocchino
authors: Section of Respiratory Diseases, Department of Surgery and Clinical Medicine, University Federico II, Naples; Unit of Pathology, AORN Ospedali dei Colli, Naples, Italy; Unit of Pathology, AO G. Rummo, Benevento, Italy.
authors: Giacomo
authors: G
authors: Zuccarini
authors: Section of Respiratory Diseases, Department of Surgery and Clinical Medicine, University Federico II, Naples; Unit of Pathology, AORN Ospedali dei Colli, Naples, Italy; Unit of Pathology, AO G. Rummo, Benevento, Italy.
authors: Gerardo
authors: G
authors: Ferrara
authors: Section of Respiratory Diseases, Department of Surgery and Clinical Medicine, University Federico II, Naples; Unit of Pathology, AORN Ospedali dei Colli, Naples, Italy; Unit of Pathology, AO G. Rummo, Benevento, Italy.
authors: Alessandro
authors: A
authors: Sanduzzi
mesh_terms: D000068879:Adalimumab / Q000008:administration & dosage / Q000009:adverse effects*; D000368:Aged; D018501:Antirheumatic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D000995:Antitubercular Agents / Q000627:therapeutic use; D001172:Arthritis, Rheumatoid / Q000150:complications / Q000188:drug therapy; D003937:Diagnosis, Differential; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D016867:Immunocompromised Host; D008727:Methotrexate / Q000008:administration & dosage* / Q000009:adverse effects; D000069283:Rituximab / Q000008:administration & dosage; D014060:Tongue Diseases / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology; D016896:Treatment Outcome; D014393:Tuberculosis, Oral / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology
chemical_list: D018501:Antirheumatic Agents; D000995:Antitubercular Agents; D000069283:Rituximab; D000068879:Adalimumab; D008727:Methotrexate