Tumor Necrosis Factor Blockers and Reactivation of Latent Tuberculosis

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Abstract
Patients with rheumatoid arthritis (RA) may be at increased risk of reactivation of infectious diseases that normally remain latent in granuloma (e.g., tuberculosis and histoplasmosis). This may be because of an immunosuppressed state that accompanies autoimmune disease or because of immunosuppressive treatments, such as steroids or monoclonal anti-TNF antibodies (mAb). Among immunosuppressed patients, we expect the pattern of tuberculosis disease to be unusual, with a higher incidence of extrapulmonary and disseminated disease than among immunocompetent patients. Unlike fungal disease, the prescribing physician thankfully can perform tests and administer anti-tuberculosis prophylaxis to prevent tuberculous complications associated with autoimmune disease and treatment. In the United States, an increased risk of reactivation tuberculosis in RA has been suggested but not proven, but it has been demonstrated for patients with RA taking infliximab, a monoclonal TNF blocker [1].