Background/Purpose: Tumor necrosis factor-α inhibitors (TNF-I) are commonly used today to treat a wide variety of immune-mediated disorders. These medications are linked with an increased risk of mycobacterial, viral, and fungal infections, and some society guidelines recommend screening for tuberculosis (TB), hepatitis B (HBV) and C (HCV), human immunodeficiency virus (HIV), and active life-threatening fungal infections. The aim of our study was to determine the number of patients with infectious diseases identified on screening; and to describe what evaluation, treatment, and follow-up transpired for these individuals.  

Methods: We electronically searched for all patients receiving TNF-I from 9/4/2010 to 4/22/2015.  The records for patients screening positive for HBV, HCV, TB, and HIV were then reviewed in detail.  

Results: 2218 individuals received TNF-I during the study period. 656 patients had at least one of the following laboratory tests checked: hepatitis B surface antibody (HBsAb), hepatitis B surface antigen (HBsAg), and hepatitis B core antibodies (HBc total Ab). Of these, 37 (5.6%) were positive for HBsAb only, 1 (0.1%) was positive for HBsAg only, 3 (0.5%) were positive for HBc total Ab only, and 5 (0.8%) were positive for both HBsAb and HBc total Ab. One patient had a known history of chronic HBV prior to the initiation of a TNF-I, and one patient was tested due to the development of symptoms only. Thus, there were 7 (1.0%) new diagnoses of HBV diagnosed by screening. All 7 cases were maintained or eventually started on their TNF-I. One case received treatment with lamivudine when started on a TNF-I.             662 patients were tested for HCV via antibody test, and 2 (0.3%) were found to be positive on pre-screening. Follow-up RNA testing was negative in one case and positive in the other. The latter patient was referred to Hepatology, and the initiation of the TNF-I was delayed due to the new diagnosis.                   557 were tested for TB via the QuantiFERON-TB Gold In-Tube assay, and 13 (2.3%) were positive. After excluding patients who had a known history of latent TB and those who were tested due to the development of symptoms only, there were a total of 7 (1.3%) new diagnoses of TB found on screening. Five (71.4%) cases were diagnosed with latent TB, and were appropriately treated. TNF-I was initiated in 4/5 cases after > 1 month of treatment with isoniazid. Two positive assays found on pre-screening were thought to be false positives, and TNF-I was initiated with no TB treatment.             Two patients were screened for HIV with an antigen and antibody combination assay, and both were negative.

Conclusion: Few new cases, and no active cases, of HBV, HCV, TB, and HIV are identified in recipients of TNF-I therapy during routine screening.