Tuberkulozni spondilodiscitis u bolesnika s psorijatičnim artritisom liječenog ciljanim sintetskim antireumatskim lijekovima koji modificiraju bolest – prikaz bolesnika

Tuberculosis (TB) has been recognised as an important opportunistic infection that occurs in patients with inflammatory rheumatic diseases. The results of global registries show that the risk of reactivation of latent TB or the development of new TB infection increases in patients treated with tumour necrosis factor inhibitors (TNFis). However, the results of randomised clinical studies and few data from everyday practice show that targeted synthetic disease- modifying anti-rheumatic drugs (tsDMARD s) such as apremilast and janus kinase inhibitors (JAK i), have a lower risk of TB activation compared to TNFis. In this article, we shall present a male patient in whose case skin psoriasis preceded the development of articular involvement, and the definite diagnosis of psoriatic arthritis (PsA). He was treated with conventional synthetic diseasemodifying anti-rheumatic drugs (csDMARD s) methotrexate and sulfasalazine, and, following that, with tsDMARD s apremilast and tofacitinib, with previously obtained negative results of hepatitis markers and QuantiFERON -TB Gold (QFT) test for latent tuberculosis. Considering the intense pain in the lumbosacral segment of the spine along with the occurrence of fever and alteration of serological inflammatory laboratory markers, the diagnostic evaluation was performed in order to determine the presence of TB spondylodiscitis L5-S1 with epidural abscess and abscess in the right psoas muscle. Specific therapy was discontinued, and, following that, surgical abscess drainage, and microdiscectomy and vertebrosynthesis of the L5-S1 lumbosacral joint were performed. In addition to that, the anti-TB therapy was induced for a total duration of 12 months. In conclusion, this is the first case report in literature which discusses the case of tuberculous spondylodiscitis in patients with PsA treated with tofacitinib. The patient had been treated with apremilast for 3 months a year earlier, but the connection between the use of the aforementioned drug and the development of extrapulmonary tuberculosis was not established. Results from national registries need to be collected due to the fact that phase III randomised controlled trials did not register any cases of TB in PsA patients treated with tofacitinib. In the event of symptoms that do not fit into the clinical features of PsA, the possibility of developing pulmonary or extrapulmonary TB manifestations should be considered even though the patient is being treated with tsDMARD s.Tuberkuloza (TBC ) je prepoznata kao važna oportunistička infekcija koja se javlja u bolesnika s upalnim reumatskim bolestima. Rezultati svjetskih registara pokazuju da se rizik od reaktivacije latentne TBC ili nastanka nove TBC - infekcije povećava u bolesnika liječenih inhibitorima faktora tumorske nekroze (TNFi). Dok rezultati randomiziranih kliničkih studija i malobrojni podatci iz svakodnevne prakse pokazuju da ciljani sintetski antireumatski lijekovi koji modificiraju bolest (eng. targeted synthetic disease-modifying anti-rheumatic drugs; tsDMARD ), kao što su apremilast te inhibitori janus-kinaza (JAK -i), imaju niži rizik za aktivaciju TBC -a u usporedbi s TNFi. U ovom članku prikazati ćemo bolesnika u kojega je dugi niz godina psorijaza kože prethodila razvoju zglobnih tegoba i postavljanju dijagnoze psorijatičnog artritisa (PsA). Liječen je konvencionalnim sintetskim antireumatskim lijekovima koji modificiraju bolest (eng. conventional synthetic disease-modifying anti-rheumatic drugs; csDMARD ) metotreksatom i sulfasalazinom, te potom i tsDMARD -ovima apremilastom i tofacitinibom, uz prethodno utvrđene negativne nalaze hepatitis markera i kvantiferonskog testa na latentnu tuberkulozu. S obzirom na intenzivnu bolnost lumbosakralnog segmenta kralježnice uz febrilitet i alteraciju upalnih laboratorijskih parametara, učini se dijagnostička obrada kojom se utvrdi postojanje tuberkuloznog spondilodiscitisa L5-S1, epiduralnog apscesa i apscesa desnog mišića psoasa. Ukine se specifična terapija te se učini kirurška evakuacija apscesa, mikrodiscektomija i vertebrosinteza L5-S1 te započne antituberkulotska terapija u ukupnom trajanju od 12 mjeseci. Zaključno, ovo je prvi prikaz u literaturi tuberkuloznog spondilodiscitisa u bolesnika sa PsA liječenog tofacitinibom. Pacijent je godinu dana ranije bio liječen apremilastom tri mjeseca, ali ga ne možemo povezati s razvojem ekstrapulmonalne tuberkuloze. Potrebno je prikupiti rezultate iz nacionalnih registara s obzirom na to da randomizirane kontrolirane studije faze III nisu registrirale niti jedan slučaj TBC -a u pacijenata s PsA liječenih tofacitinibom. Kod pojave simptoma koji se ne uklapaju u kliničku sliku PsA, treba razmišljati o mogućnosti razvoja pulmonalne ili ekstrapulmonalne manifestacije tuberkuloze iako se bolesnik liječi tsDMARD -om