TNF-α inhibitor administration in psoriatic arthritis patient with latent tuberculosis and cardiovascular disease as an extra articular manifestation

Abstract

Introduction: Psoriatic arthritis is a spondyloarthropathy subtype with a broad clinical spectrum and diverse symptoms. The use of biological disease-modifying antirheumatic medications (DMARDs), such as TNF inhibitors is recommended as pharmacological therapy for PSA in cases of axial involvement and high disease activity level. Since Indonesia has the second-highest tuberculosis (TB) cases globally, and patients receiving TNF inhibitors have an elevated risk of latent TB reactivation, evaluation of latent TB before starting TNFi is necessary and challenging. Case Presentation: A 63-year-old male psoriatic arthritis patient with bilateral hip joint osteoarthritis, bilateral knee effusions and bilateral frozen shoulder. The patient also had coronary heart disease with a history of underwent coronary artery bypass graft (CABG), diabetes mellites type 2 and confirmed latent TB. Psoriatic arthritis had high activity based on the Bath Ankylosing Spondylitis Disease Activity (BASDAI) score and Ankylosing Spondylitis Disease Activity Score (ASDAS). TNF inhibitor treatment started a month after latent TB treatment. The patient responded satisfactorily to the TNFi treatment, as demonstrated by clinical evaluation and decreased disease activity. Latent TB treatment was continued for up to six months, followed by latent TB activity monitoring during TNFi administration to prevent latent TB reactivation. Conclusion: This case highlights the challenges in management of axial psoriatic arthritis patients with high disease activity, concomitant latent TB infection, and early extra-articular symptoms of cardiovascular disease.