Infliximab, a tumor necrosis alpha (TNFα) inhibitor, may cause reactivation of latent tuberculosis.  Here we present a patient with inflammatory bowel disease who developed reactivated tuberculosis and tuberculous meningitis during infliximab treatment.  Quantiferon-TB Gold testing prior to institution of therapy was negative and remained indeterminate throughout his course.  The possibility of tuberculous meningitis was initially called into question because of a mildly elevated angiotensin converting enzyme (ACE) levels in cerebrospinal fluid.

CASE: This 40 year old man, who had once lived in an area of endemic tuberculosis, was diagnosed with inflammatory bowel disease.  He was screened for latent TB with Quantiferon-TB Gold testing and then treated with infliximab.  He subsequently developed lymphadenopathy, lethargy, fever, and increasingly severe headache.  CSF showed a mixed pleocytosis and increasing hypoglychorrhachia, with evidence of diffuse meningitis on MRI.   Lumbar and ventricular CSF remained negative by culture for M. tuberculosis.  Although the possibility of tuberculous meningitis was briefly called into question because of an elevated CSF ACE level with normal ACE blood levels, the patient was treated presumptively for tuberculous meningitis.  M. tuberculosis was subsequently detected in lymph node biopsy and broncheoalveolar lavage; and M. tuberculosis DNA was detected in CSF by metagenomic next generation sequencing.  The patient’s course was complicated by unprovoked pulmonary emboli, eventually causing the patient’s death.