title: Concomitant disseminated histoplasmosis and disseminated tuberculosis after tumor necrosis factor inhibitor treatment: a case report.
abstract: Tumor necrosis factor antagonist inhibitors have transformed the approach to patients with severe autoimmune conditions, such as rheumatoid arthritis. Although the therapy can be highly effective, TNF-α inhibitors are associated with an increased risk of opportunistic infections.
  
  
  
  Here, we report a case of concomitant disseminated histoplasmosis and tuberculosis in a 65-year-old female with rheumatoid arthritis treated with TNF-α inhibitor. Both conditions can be found in disseminated form in immunosuppressed hosts, but co-infection is rare with only a few cases having been reported, to our knowledge, all in HIV patients.
  
  
  
  This case posed a considerable challenge for diagnosis and treatment due to the unusual disseminated co-infection, the overlapping symptoms, and the interactions between medications.
authors.affiliation: JEMO: Family Medicine Residency Program, Manatí Medical Center, P.O Box 1142, Manatí, PR, 00674, USA.
authors.forename: Juan E
authors.initials: JE
authors.lastname: Muñoz-Oca
authors.affiliation: MLVM: Department of Medical Education, Manatí Medical Center, P.O Box 1142, Manatí, PR, 00674, USA. mvillarreal@mmcaol.com.
authors.forename: Martha L
authors.initials: ML
authors.lastname: Villarreal Morales
authors.affiliation: ANR: Department of Family Medicine, Manatí Medical Center, P.O Box 1142, Manatí, PR, 00674, USA.
authors.forename: Aracelis
authors.initials: A
authors.lastname: Nieves-Rodriguez
authors.affiliation: LMB: Department of Internal Medicine /Infectious diseases, Manatí Medical Center, P.O Box 1142, Manatí, PR, 00674, USA. lemuelmartinez.md@outlook.com.
authors.forename: Lemuel
authors.initials: L
authors.lastname: Martínez-Bonilla
mesh_terms: D000068879:Adalimumab / Q000009:adverse effects*; D000368:Aged; D000935:Antifungal Agents / Q000627:therapeutic use; D018501:Antirheumatic Agents / Q000009:adverse effects*; D000995:Antitubercular Agents / Q000627:therapeutic use; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D060085:Coinfection; D005260:Female; D006660:Histoplasmosis / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000209:etiology / Q000276:immunology*; D006801:Humans; D016867:Immunocompromised Host; D009894:Opportunistic Infections / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000209:etiology / Q000276:immunology*; D014057:Tomography, X-Ray Computed; D014376:Tuberculosis / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000209:etiology / Q000276:immunology*; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors
chemical_list: D000935:Antifungal Agents; D018501:Antirheumatic Agents; D000995:Antitubercular Agents; D014409:Tumor Necrosis Factor-alpha; D000068879:Adalimumab
keywords: Adalimumab; Case report; Co-infection; Histoplasmosis; TNF-α inhibitors; Tuberculosis