Navigating tuberculosis therapy in acute intermittent porphyria: A case report and narrative review
Abstract
Tuberculosis (TB) treatment in patients with acute intermittent porphyria (AIP) is challenging because several first-line antituberculous drugs can precipitate porphyric crises, and evidence to guide management is limited.
We describe a 26-year-old woman with peritoneal TB who developed acute abdominal pain, hyponatraemia, seizures, and neuropsychiatric manifestations within 24 hours of standard isoniazid (H), rifampicin (R), pyrazinamide (Z), and ethambutol (E) therapy. AIP was confirmed by elevated urinary porphobilinogen levels, and the patient required hemin for the acute crises. Antituberculous therapy was modified to a rifampicin-free regimen including moxifloxacin, linezolid, and ethambutol; isoniazid was cautiously reintroduced once the patient had stabilised.
Recurrent porphyric crises and treatment-related toxicity ultimately led to therapy discontinuation after 167 doses. The patient achieved substantial neurological recovery without TB relapse after one year of follow-up.
This case illustrates the need to balance TB control with porphyria safety, and to consider acute hepatic porphyria when patients develop unexplained abdominal pain, hyponatraemia, or neurological symptoms after starting antituberculous therapy. Rifampicin and isoniazid carry the highest porphyrinogenic risk, whereas moxifloxacin, ethambutol, and linezolid appear to be safer alternatives. Given limited evidence and the absence of standardised protocols for this rare coexistence, we offer a…
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