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Cutaneous tuberculosis revealed by infliximab therapy for presumed sarcoidosis

Tumour necrosis factor (TNF)-a inhibitors have had a considerable effect on the treatment of psoriasis, and their use has extended to other dermatological conditions. The immune response to granulomatous infection is inhibited by these agents, so patients are at risk of Mycobacterium tuberculosis infection. We present a case of cutaneous tuberculosis after infliximab therapy for presumed sarcoidosis. An 18-year-old girl presented with an enlarging erythematous plaque on the left thigh. Histological examination revealed numerous well-formed, noncaseating granulomas. Stains for acid-fast and alcohol-fast bacilli and fungi were negative, as was culture for mycobacteria. Serum angiotensin levels, chest X-ray and pulmonary function tests were normal. Cutaneous sarcoidosis was the favoured diagnosis. The patient subsequently developed inflammatory plaques on the ear and nose, and failed to respond to sequential treatments including oral hydroxychloroquine, prednisolone, methotrexate and pentoxyphilline over 30 months. Infliximab has been used successfully in recalcitrant cutaneous sarcoidosis, and thus was instigated after appropriate investigations. The patient developed a grade 2 reaction to the tuberculin test, but as chest X-ray was normal, it was deemed suitable, according to available British Thoracic Society guidelines at the time, to proceed with the treatment. After two infusions, the cutaneous disease worsened significantly with a florid inflammatory plaque developing on the nose (Fig. 1a). On repeat biopsy, a less well-formed granulomatous infiltrate was seen, with evidence of acidfast bacilli under the microscope (Fig. 1b). The patient was started on quadruple antituberculous treatment [fixed-dose combination tablet of rifampicin, isoniazid and pyrazinamide (Rifater; Sanofi-Aventis, Guildford, Surrey, UK), plus ethambutol and pyridoxine] for 2 months, then rifampicin, isoniazid, ethambutol and pyridoxine for a further 4 months, with continuation of prednisolone. Methotrexate was stopped, and the skin lesions improved dramatically. Subsequent M. tuberculosis cultures were negative but the excellent response to antituberculous treatment (b) (a)