Introduction Biologic treatment has been associated with 5-fold increased risk of tuberculosis (TB). Latent TB infection (LTBI) screening should be performed on all inflammatory bowel disease (IBD) patients prior to initiating biologic treatment. We analysed cases of active TB after receiving biologic treatment in IBD patients. Methods All TB patients were identified from Leicester, Leicestershire and Rutland (LLR) TB database case notification between January 2007 to July 2022. All IBD patients who received biologic treatment during this time period were identified from the University Hospitals of Leicester high-cost funding pharmacy database. Those who developed active TB while on biologic treatment were identified after data matching. Clinical and electronic notes were reviewed. LTBI biologic screening utilises full history, CXR, QuantiFERON or T-spot TB assay since 2007 and Mantoux testing in selected cases prior to that. Results During this 15-year period, 3089 cases of TB notifications were recorded in the LLR TB database. 1508 IBD patients were treated with biologics during the study period, and of those, 6 (3 Crohn's Disease and 3 Ulcerative Colitis) (0.4%) subsequently developed active TB after the biologic treatment. Four were male and the age range was 27–45 years. Four were Caucasian of UK origin, the other 2 were from Slovakia and India. BCG vaccination status was only known for 2 out of 6 (1 vaccinated). Four had negative QuantiFERON assays on biologic screening. One case was started on biologic treatment in the private sector and screening information was limited. One was treated prior to the availability of IGRA assays. All patients had a normal CXR prior to anti-TNF and none of them had received LTBI treatment. Three patients each were on Adalimumab or Infliximab at the time of TB diagnosis. Time from initiation of anti-TNF to TB diagnosis ranged from 3 to 108 months. All active cases had fully sensitive culture confirmed TB. The disease site was pulmonary in 4 cases and miliary in 2 cases. Two of the pulmonary cases had pericardial or peritoneal involvement, respectively. TB treatment duration was between 6–12 months depending on the site and severity of TB. Conclusion The overall incidence of active TB was low and the majority of the identified 6 cases were considered low epidemiological risk for LTBI. None had abnormal chest imaging and of those tested, none had a positive QuantiFERON assay before the start of the anti-TNF treatment. It is unknown if the cases represented de novo infection or reactivation of remotely acquired LTBI. Re-screening may have informed opportunities for prevention treatment. Ongoing surveillance for LTBI is imperative in biologic treated IBD patients, particularly following travel to endemic countries, high-risk exposures and in the context of drug therapy escalation. Active collaboration with the TB service, especially for those requiring urgent immunosuppression, is of critical value for comprehensive care.
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