AB0644 Mortality of tuberculosis in rheumatoid arthritis – a retrospective clinicopathologic study of 234 autopsy patients
Authors: Á. Apáthy, M. Bély
Journal: Annals of the Rheumatic Diseases (2013)

<h3>Background</h3> The risk of tuberculosis is higher in <i>rheumatoid arthritis</i> (<b>RA</b>) or other autoimmune diseases than in a normal population. <h3>Objectives</h3> The <b>aim</b> of this study was to determine the <i>mortality</i> due to tuberculosis (<b>Tb</b>) or miliary disseminated tuberculosis (<b>mTb</b>) in <b>RA</b>, and the incidence of clinically <i>missed diagnosis</i> of <b>Tb</b> or <b>mTb</b> in <b>RA</b>. <h3>Methods</h3> A randomized autopsy population of <b>234</b> in-patients with <b>RA</b> was studied. <b>RA</b> was diagnosed clinically according to the <b>ARA</b> criteria. The post-primary tuberculosis, the miliary dissemination and mortality of tuberculosis were histologically diagnosed post mortem. The cases with clinically <i>missed diagnosis</i> of <b>Tb</b> or <b>mTb</b> were analysed retrospectively by reviewing the clinical and pathological reports, tissue samples and the histological slides. <h3>Results</h3> Post-primary fibrous, or fibrocaseous tuberculosis accompanied <b>RA</b> in <b>27</b> (11.5%) of 234 cases. Post-primary tuberculosis was localized to the lungs. <b>Twelve</b> of 27 post-primary <b>Tb</b> cases were histologically fibrocaseous, and <b>15</b> of 27 revealed only fibrous tuberculotic scars. In <b>8</b> of 27 patients (3.41% of 234, and 29.63% of 27), tuberculosis was accompanied by active (<b>miliary</b>) <b>dissemination</b> (29.62% of 27, and 3.42% of 234 patients). All <b>8</b> patients were <b>females</b>. Tuberculosis led to death in <b>3</b> cases (1.28% of 234, 1.11% of 27, and 37.5% of 8). <b>Two</b> patients died of circulatory failure due to <b>Tb</b> complicated by miliary dissemination and <b>one</b> died by massive internal bleeding due to propagation of fibrocaseous cavernosus tuberculotic foci and erosion of a small branch of a pulmonary artery (11.11% of 27, and 1.28% of 234 patients). Tuberculosis was clinically recognized only in this latter of three lethal cases (3.7% of 27); in 26 patients (with or without miliary dissemination, and with or without lethal outcome) tuberculosis were clinically missed (96.3% of 27). <h3>Conclusions</h3> In our autopsy population three of 234 <b>RA</b> patients died of tuberculosis and miliary dissemination. However, only one of 27 post-primary tuberculosis cases was clinically detected. Coexisting complications modify the basic disease (<b>RA</b>) and present atypical clinical manifestations (1). The atypical symptoms may lead to incorrect diagnosis or late recognition of the complications or associated diseases. The age of the patients, the autoimmune character of the underlying disease, the steroid and/or immunosuppressive treatment may also play a role in missing the diagnosis of miliary tuberculosis. Excluding <b>Tb</b> in autoimmune disease may be difficult. Recognizing the diagnostic clinical-laboratory parameters (2) and/or knowledge of any histological evidence of existing <b>Tb</b> is crucial in the patients' history. The histological diagnosis of <b>Tb</b> is straight forward in most cases, but rheumatoid nodules in the lungs may cause differential diagnostic problems. <h3>References</h3> <b>Apáthy Ágnes, Bély M</b>: Co-morbidity in Rheumatoid Arthritis: Influence of Associated Diseases on the Prevalence of Co-existent Complications of RA - A Retrospective Clinicopathologic Statistical Study of 234 Autopsy Patients. Ann Rheum Dis 2009; 68(Suppl. 3): 407-408 www.abstracts2view.com/eular/ <b>Apáthy Ágnes, Bély M</b>: Miliary Dissemination of Tuberculosis in Rheumatoid Arthritis - Clinical-laboratory parameters, demographics and duration of disease associated with miliary tuberculosis. A retrospective clinicopathologic study of 161 autopsy patients. Ann Rheum Dis 2004; 63(Suppl 1): 167 <h3>Disclosure of Interest</h3> None Declared