Chest X-ray prior to biological treatment in inflammatory bowel diseases: it is not only about tuberculosis – a case report and literature review

Background Biological treatments have substantially improved management of inflammatory bowel disease, but their profound immunosuppressive effects necessitate infection screening before initiation. Current guidelines recommend chest X-ray (CXR) alongside Mycobacterium tuberculosis testing. While this approach is widely accepted, the necessity of routine CXR in patients without tuberculosis (TB) risk factors has recently been questioned in low-incidence regions. Methods We report a rare case of a patient with ulcerative colitis undergoing routine preinfliximab CXR revealing an apical right-lung infiltrate, that was not suspected based on clinical assessment and negative interferon-gamma release assays testing. In addition, we summarize the existing literature on invasive aspergillosis associated with tumor necrosis factor alpha inhibitors. Results The patient had minimal clinical symptoms of pulmonary infection and remained afebrile with consistently normal C-reactive protein levels. Nevertheless, routine pretreatment CXR demonstrated an apical right-lung infiltrate, leading to cancelation of planned infliximab initiation. Subsequent analyses of bronchoalveolar fluid and sputum identified two strains of Aspergillus fumigatus . Despite prolonged antifungal therapy, the patient ultimately required a right-lung lobectomy. A comprehensive literature review identified three fatal cases of invasive aspergillosis following tumor necrosis factor alpha inhibitors, underscoring the clinical importance of detecting serious pulmonary infections prior to treatment initiation. Conclusions Our case is, to our knowledge, the first report in inflammatory bowel disease to illustrate that CXR may uncover potentially life-threatening infections beyond TB in patients with limited clinical and biochemical signs of infection, supporting its continued role in prebiologic treatment workflows even in low-TB prevalence settings.