Document resource
Tuberculosis (TB) is a recognised complication in adult patients with inflammatory bowel disease (IBD) receiving biologic treatment. 1 In contrast, paediatric cases are less commonly reported.2 3 Despite this, children undergoing immunosuppressive treatment are at increased risk for severe and atypical presentations of TB.4 Therefore, maintaining a high index of suspicion and ensuring early diagnostic evaluation is critical. We describe two paediatric patients with Crohn’s disease who developed TB during biologic therapy.The first case involves a 19-year-old female initially diagnosed with Budd Chiari syndrome and IBD unclassified (IBD-U) at age 5, later confirmed as Crohn’s disease. She was treated with azathioprine and infliximab but later switched to adalimumab due to antibody formation. She had BCG vaccination as a baby and her pre-biologic QuantiFERON was negative. While visiting India at age 12, she developed fever, abdominal pain, and weight loss. Imaging revealed bilateral pulmonary nodules and sputum for acid fast bacilli was positive. She completed a 6-month treatment for pulmonary tuberculosis (3 months of intensive therapy with rifampicin, ethambutol, pyrazinamide and pyridoxine and 3 months of maintenance therapy with rifampicin and pyridoxine) and she made a full recovery. Her biologics were re-started after completing anti TB treatment. She later required change of biologics to Vedolizumab due to ongoing active inflammation of the colon. She has subsequently transitioned to adult services at age 17 on vedolizumab.The second is an 11-year-old boy diagnosed with Crohn’s disease at age 10. Initially treated with infliximab, he was switched to adalimumab due to allergic reaction. He did not receive BCG at birth (not recommended) however, his pre-infliximab QuantiFERON was negative. A year after diagnosis, after a trip to Poland, he presented with prolonged fever without classical tuberculosis symptoms. His biologic treatment was stopped. Initial investigations were inconclusive (normal chest X-ray and slightly raised inflammatory markers). Whole-body MRI and subsequent chest-CT revealed pulmonary consolidation. Despite broad-spectrum antibiotics and antifungals, fever persisted. His repeat QuantiFERON was indeterminate. He later developed anaemia, thrombocytopenia, and markedly elevated ferritin, suggestive of an immune-mediated response. Gastric washing for acid fast bacilli was positive, and his culture yielded rifampicin-sensitive mycobacterium tuberculosis. At this time, he had developed features of miliary TB on his chest X-ray. He was treated with intravenous steroids and intravenous anti-TB therapy (rifampicin, isoniazid, linezolid and levofloxacin) due to clinical severity. These were later switched to rifampicin, ethambutol, levofloxacin, pyrazinamide and pyridoxine, on account of persistent thrombocytopenia. He continued to make significant improvement and was discharged home on oral medications.The risk of tuberculosis remains a serious clinical consideration in children with IBD on biologic treatment. To mitigate this risk, it is essential that all patients undergo appropriate TB screening prior to initiating biologic treatment, in line with the ESPGHAN guidelines. A high index of suspicion following travel to countries with elevated TB prevalence is essential, and appropriate precautions should be undertaken by families during such travels. The clinical presentation may be atypical and subtle and even an isolated fever should prompt consideration of TB in this vulnerable population.References Azevedo FC, Barros LL, Justus FF, et al. Active tuberculosis in inflammatory bowel disease patients: a case-control study. Therap Adv Gastroenterol. 2023 Jul 4;16.Cruz AT, Karam LB, Orth RC, et al. Disseminated tuberculosis in 2 children with inflammatory bowel disease receiving infliximab. Pediatric Infectious Disease Journal 33(7):779–781.Telefon AH, Cil MK, Sonmez G, et al. Balancing effective treatments with potential threats: the impact of biologic agent use on tuberculosis development in children with chronic inflammatory disorders. Int J Rheum Dis. 2025 Feb;28(2):e70145.Parigi S, Licari A, Manti S, et al. Tuberculosis and TNF alpha inhibitors in children: how to manage a fine balance. Acta Biomed. 2020 Sep 15;91(11-S):e2020009.