Anti-Mycobacterial Treatment: An Option for Refractory Inflammatory Bowel Disease?

Elif Sarıtaş Yüksel, Cem Cekic, Firdevs Topal

Elif Sarıtaş Yüksel, Associate Prof in Gastroenterology department, İzmir Teaching and Research Hospital and Katip Celebi University, Turkey
Cem Cekic, İzmir Teaching and Research Hospital and Katip Celebi University, Turkey
Firdevs Topal, İzmir Teaching and Research Hospital and Katip Celebi University, Turkey

Correspondence to: Elif Sarıtaş Yüksel, Associate Prof in Gastroenterology department, İzmir Teaching and Research Hospital and Katip Celebi University, Turkey.
Email: elifsaritas35@gmail.com
Telephone: +905326728797
Received: August 19, 2014
Revised: November 19, 2014
Accepted: November 25, 2014
Published online: December 21, 2014


We hereby bringout three patients with activation of latent TB under anti TNF treatment.

© 2014 The Authors. Published by ACT Publishing Group Ltd.

Yüksel ES, Cekic C, Topal F. Anti-Mycobacterial Treatment: An Option for Refractory Inflammatory Bowel Disease?. Journal of Gastroenterology and Hepatology Research 2014; 3(12): 1405-1406 Available from: URL: http://www.ghrnet.org/index.php/joghr/article/view/982


We hereby bring out three patients with inflammatory bowel disease (IBD) who developed tuberculosis (TB) after the start of anti tumor necrosis factor alpha (anti-TNFα) in spite of negative TB screening. Screening and treatment of latent TB infection (LTBI) in inflammatory bowel disease patients considered for anti tumor necrosis factor alpha (anti-TNFα) treatment are problematic due to the lack of a gold standart diagnostic technique for LTBI. Turkey is among the countries with intermediate TB incidence. According to our national guidelines revised in 2005, patients with a history of untreated or partially treated TB or exposure to an active case of TB, with a tuberculin skin test (TST) ≥5 mm or fibrotic lesions on postero-anterior chest radiography (CXR) are indicated for prophylaxis. Booster TST is recommended for patients with anergic and even negative TST results. Bacille Calmette Guerin (BCG) vaccination is in our national schedule hence Interferon Gamma Release Assay (IGRA) test is also performed prior to the anti-TNFα treatment.

In contrary to the patients presented by Debeuckelaere[1], our three patients who developed TB did not have reactivation of IBD throughout the whole anti TB treatment period although anti-TNFα was their third line treatment and their IBD course was severe from the beginning. However they relapsed after the cessation of the antibiotics.

A current meta-analysis of genome-wide association studies (GWAS), including more than 75,000 patients and controls, demonstrated a considerable overlap between susceptibility loci for IBD and mycobacterial infection[2]. Human studies and animal models have demonstrated that Intestinal bacteria may play a key role in IBD[3,4] and antibiotic treatment can reduce activity of IBD.

Granulomas are the aggregates of the immune cells, predominantly macrophages which are the cells of the innate immunity system and granulomas form when the agent can not be killed but captured. This fact brings the question if Crohn's disease (CD) is initiated by an infectious agent especially mycobacterium with a simultaneous defect in the innate immunity. Olsen et al assesed the frequency of mycobacteria reactive T cells in intestinal biopsies from patients with IBD[5]. Their finding of high frequencies of mycobacteria reactive T cells present particularly in CD patients seems to be reasonable for anti-mycobacterial therapy together with immunosuppressive drugs.

Our three patients benefiting from anti-TB treatment for the maintenance of IBD remission give the idea that anti-mycobacteria treatment might be an option for a subgroup of IBD patients conceivably living in regions with high TB burden or with genetic susceptibility for mycobacterial infection.


The authors declare that they have no conflict of interests and received no financial support.


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Peer reviewers: Emad H Aly MBBCh, MS, MD, FRCS, MEd, Consultant Colorectal & General Surgeon, Laparoscopic Colorectal Surgery & Training Unit, Aberdeen Royal Infirmary, Honorary Senior Lecturer, University of Aberdeen, ASGBI Director for Surgical Education, Aberdeen Royal Infirmary, Ward 34, Foresterhill, Aberdeen, AB25 2ZN, UK.


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