Case Report and literature review: complications of the association between rheumatoid arthritis and tuberculosis

Abstract

Pulmonary tuberculosis is one of the major public health issues globally. According to the World Health Organization, it is among the top 10 causes of death caused by a single pathogen. In Romania, its reported incidence rate in 2024 was approximately 60 per 100,000 people, making it the country with the highest incidence in Europe. Rheumatoid arthritis (RA) is a systemic chronic autoimmune inflammatory disease characterized by the destruction of the small joints along with symmetrical distribution and multiorgan involvement. Pulmonary manifestations are more common in males with positive serology and can involve the lungs, airways, or pleura. Short-term corticotherapy may be initiated in patients with severe symptoms, and biological therapy (anti-TNF alpha drugs) may be used in those with inefficiency of disease-modifying antirheumatic drugs, with an increased risk for disseminated forms of tuberculosis in those with latent infection. We present the case of a 38-year-old male patient with a 5-year history of seropositive RA who was treated with methotrexate and methylprednisolone, without any prior investigations for latent tuberculosis infection or any chest radiography performed, and was admitted with severe respiratory failure. The results of thoracic computed tomography showed bilateral pneumothorax and pneumomediastinum, with pulmonary lesions suggestive of a diagnosis of tuberculosis, which was confirmed by bacteriological testing of samples. The coexistence of two severe diseases—one requiring immunosuppressive treatment and the other one favored by immunosuppression—in a country with a high prevalence of tuberculosis infection and in the absence of latent tuberculosis infection screening or periodic pulmonological assessment can lead to severe, life-threatening complications that require complex, multidisciplinary, long-term, and expensive management.