A 37-year-old man under anti-Tumor Necrosis Factor (TNF) therapy for Crohn's disease, presented with otalgia and hearing impairment on the right side for five days. Otoscopic examination showed redness and swelling of the right tympanic membrane, indicative of acute otitis media. Administration of oral antibiotics relieved his ear pain, but fluid retention in the middle ear remained. After 28 days, a tympanostomy tube was inserted, but otorrhea began to persist. Four months later, white lesions appeared in the anterior lower quadrant of the tympanic membrane. The patient also began to complain of pharyngalgia, and endoscopy revealed inflammatory swelling and white patches on the superior pharyngeal wall, the epiglottis, and the aryepiglottic folds. At this point, tuberculosis infection was suspected. Acid-fast bacillus smear and PCR from the otorrhea and pharyngeal wipe both tested positive for tuberculosis. Pathologically, lymphocytic infiltrations with multiple granulomas containing multinucleated giant cells were seen in the pharyngeal membrane, and multiple Ziehl-Neelsen-positive cells were found from the middle ear tissue. Subsequently, TNF-α inhibitor was discontinued, and antituberculosis drugs were administrated. Nine months later, inflammatory findings of the middle ear and laryngopharyngeal mucosa improved.
Tuberculosis is an important differential diagnosis of refractory otitis media, especially in patients receiving immunosuppressant agents such as a TNF-α inhibitor.
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