EC Pulmonology and Respiratory Medicine

Introduction: Coexisting complications and comorbidities modify each other and the underlying disease, producing atypical clinical manifestations.

The risk of post-primary tuberculosis (TB) is high in rheumatoid arthritis (RA).

The diagnosis of inactive or active clinically latent TB in RA is a great challenge for the rheumatologist mainly due to the limited response and treatment of elderly autoimmune patients.

This study discusses the characteristics of tuberculosis and the interactions with the coexistent complications and associated diseases on a large autopsy population with rheumatoid arthritis.

Patients (Autopsy Population) and Methods: The patients were treated and died at the National Institute of Rheumatology, Budapest, Hungary, between 1969 and 1999 in the era of steroid and conventional synthetic disease modifying anti-rheumatic drug treatment (csDMARDs), before the introduction of biological therapy (boDMARDs).

RA was confirmed clinically according to the criteria of the American College of Rheumatology (ACR).

The post-primary fibrous (fTB) or fibro-caseous (fcTB) tuberculosis with or without active miliary dissemination (mTB) was diagnosed at autopsy, confirmed and characterized microscopically by a detailed review of extensive histological material, reviewing all available clinical and pathological reports.

Results: Inactive or active TB (fTB, fcTB, mTB) developed in both sexes, and at any time in the course of RA.

The morbidity of tuberculosis was higher in elderly people with RA than in younger ones, especially aged women had a higher susceptibility for TB.

TB, especially fcTB, represented a high risk for miliary dissemination in RA.

The presence of fcTB or mTB increased the risk for mortality of RA patients, especial of women, while consolidated anthracotic scars (fTB) did not.

Women with mTB died earlier then women without mTB.

The onset, and duration of RA did not influence the prevalence and mortality of inactive or active TB.

Discussion and Conclusion: Our results suggest that the clinical diagnosis of TB with or without lethal outcome is incidental.

A detailed medical history and targeted X-ray examination, as well as the tuberculin skin test (despite its limitations) are key factors in diagnosing clinically latent TB with or without subclinical atypical miliary exacerbation.

The value of inflammatory clinical-laboratory parameters is limited; none of them is specific for tuberculosis and indicates only actual inflammatory activity.

(Based on our previous study, the decreased albumin/globulin quotient and elevated α1 and α2 globulin % of patients with moderate clinical activity of RA may indicate the reactivation of a dormant inactive tuberculotic process excluding other causes of inflammatory activity).

Histopathology remains one of the most important methods for diagnosing tuberculosis.

Granulomatous autoimmune vasculitis can be regarded as an indirect histological sign of dormant TB with or without miliary dissemination, supported by the close relationship between epithelioid granulomas and granulomatous transformation of blood vessels, independently of the origin of the tissue samples.

 Keywords: Rheumatoid Arthritis; Latent Tuberculosis; Demographics; Clinical Diagnosis; Comorbidities

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