BACKGROUND: Anti-tumour necrosis factor (TNF) therapy may be associated with 
opportunistic infections (OIs).
OBJECTIVE: To describe the spectrum of non-tuberculosis OIs associated with 
anti-TNF therapy and identify their risk factors.
METHODS: A 3-year national French registry (RATIO) collected all cases of OI in 
patients receiving anti-TNF treatment for any indication in France. A 
case-control study was performed with three controls treated with anti-TNF 
agents per case, matched for gender and underlying inflammatory disease.
RESULTS: 45 cases were collected of non-TB OIs in 43 patients receiving 
infliximab (n=29), adalimumab (n=10) or etanercept (n=4) for rheumatoid 
arthritis (n=26), spondyloarthritides (n=3), inflammatory colitis (n=8), 
psoriasis (n=1) or other conditions (n=5). One-third (33%) of OIs were bacterial 
(4 listeriosis, 4 nocardiosis, 4 atypical mycobacteriosis, 3 non-typhoid 
salmonellosis), 40% were viral (8 severe herpes zoster, 3 varicella, 3 extensive 
herpes simplex, 4 disseminated cytomegalovirus infections), 22% were fungal (5 
pneumocystosis, 3 invasive aspergillosis, 2 cryptococcosis) and 4% were 
parasitic (2 leishmaniasis). Ten patients (23%) required admission to the 
intensive care unit, and four patients (9%) died. Risk factors for OIs were 
treatment with infliximab (OR=17.6 (95% CI 4.3 - 72.9); p<0.0001)or adalimumab 
(OR=10.0 (2.3 to 44.4); p=0.002) versus etanercept, and oral steroid use >10 
mg/day or intravenous boluses during the previous year (OR=6.3 (2.0 to 20.0); 
p=0.002).
CONCLUSION: Various and severe OIs, especially those with intracellular 
micro-organisms, may develop in patients receiving anti-TNF treatment. 
Monoclonal anti-TNF antibody rather than soluble TNF receptor therapy and 
steroid use >10 mg/day are independently associated with OI.