Granulomas Galore: Concomitant Granulomatous Infections in a Patient With Crohn's Disease

TL;DR

A 74-year-old woman with Crohn's disease developed two rare infections while on a TNF-alpha inhibitor, making diagnosis and treatment difficult.

Contribution

Reports a rare case of concurrent tuberculosis and Histoplasmosis in a Crohn's patient on adalimumab.

Findings

The patient had concomitant Mycobacterium tuberculosis and Histoplasma capsulatum infections.

Diagnosis was complicated by overlapping symptoms and imaging findings.

Treatment was challenging due to drug interactions and disease progression.

Abstract

Tumor necrosis factor (TNF)-alpha inhibitors are effective biologics in the treatment of inflammatory bowel disease; however, they increase susceptibility to opportunistic infections. We report a case of a 74-year-old female with Crohn's disease who developed concomitant pulmonary tuberculosis (Mycobacterium tuberculosis [MTB]) and Histoplasmosis capsulatum infection while on adalimumab. Co-infection is rare in patients on TNF-alpha inhibitor therapy, and most cases have been reported in patients with human immunodeficiency virus (HIV). This was a challenging case for diagnosis and treatment due to indistinguishable presenting symptoms of both infections, similar laboratory and radiographical findings, and a clinical course complicated by drug-drug interactions and worsening of symptoms despite therapy.

Figures