Etanercept
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Reactions 1480, p19 - 30 Nov 2013 S Etanercept Mycobacterium poriferae infection: case report A 43-year-old woman developed a Mycobacterium poriferae infection during treatment with etanercept for psoriasis. The woman had been receiving etanercept [dosage and route not stated], a tumour necrosis factor-α (TNF-α) biologic agent for over 10 years and wished to continue treatment when she presented to a dermatology practice for treatment of her psoriasis. At the time she was doing well on topical triamcinolone and etanercept. Her physical examination showed erythematous plaques with thick white scale on all her extremities, scalp, face and trunk with a total of <10% body surface area involvement. A Mantoux tuberculin skin test was conducted and she developed 10mm of induration. Etanercept was discontinued and she was referred to a specialist in infectious diseases. Within a month of discontinuing etanercept, a severe papulopustular eruption developed on her lower legs. She also had intermittent aching pains. A QuantiFeron Gold Test (QFTB) was conducted and found to be negative. Ciclosporin was added to her topical triamcinolone therapy to treat suspected pustular psoriasis. Anti-tuberculous treatment with isoniazid and pyridoxine was initiated for latent mycobacterium tuberculosis despite her negative QFTB test. She was treated with brief courses of doxycycline and minocycline separately which did not relieve her lower extremity aching. Her clinical condition worsened with yellow discharge, tenderness, erythema and ulceration which prompted a skin biopsy from her left leg. The histopathology showed an ulcer with superficial granulation tissue and dermal fibrosis which extended to the fat. Acid-fast bacilli were identified at 8 weeks and Mycobacterium poriferae was identified by DNA sequencing at 12 weeks. At this stage she had completed 9 months of anti-tuberculous therapy. The woman was then treated with clarithromycin and ciprofloxacin. Her treatment was then changed from clarithromycin to azithromycin due to nausea. Also at this stage, she was started on treatment with ustekinumab, a non- TNF-α biologic agent. After 6 months, her leg eruption had improved significantly and after a total of 9 months on ciprofloxacin and azithromycin, it cleared. Two months after completing anti-microbial therapy, her papulopustular eruption was completely resolved. Her psoriasis was well- controlled with ustekinumab. Author comment: "Infections with non-tuberculous mycobacteria (NTM) have become more prevalent in the immunosuppressed population...All three of the commonly used anti-TNF-α therapies are linked to these infections." Laquer VT, et al. Mycobacterium porferae infection in a psoriasis patient on anti- tnf-a therapy. Dermatology Online Journal 19: No. 9, Sep 2013 - USA 803096180 1 Reactions 30 Nov 2013 No. 1480 0114-9954/13/1480-0001/$14.95 Adis © 2013 Springer International Publishing AG. All rights reserved
Transcript of Etanercept
Reactions 1480, p19 - 30 Nov 2013
SEtanercept
Mycobacterium poriferae infection: case reportA 43-year-old woman developed a Mycobacterium poriferae
infection during treatment with etanercept for psoriasis.The woman had been receiving etanercept [dosage and
route not stated], a tumour necrosis factor-α (TNF-α) biologicagent for over 10 years and wished to continue treatmentwhen she presented to a dermatology practice for treatment ofher psoriasis. At the time she was doing well on topicaltriamcinolone and etanercept. Her physical examinationshowed erythematous plaques with thick white scale on all herextremities, scalp, face and trunk with a total of <10% bodysurface area involvement. A Mantoux tuberculin skin test wasconducted and she developed 10mm of induration. Etanerceptwas discontinued and she was referred to a specialist ininfectious diseases. Within a month of discontinuingetanercept, a severe papulopustular eruption developed on herlower legs. She also had intermittent aching pains. AQuantiFeron Gold Test (QFTB) was conducted and found to benegative. Ciclosporin was added to her topical triamcinolonetherapy to treat suspected pustular psoriasis. Anti-tuberculoustreatment with isoniazid and pyridoxine was initiated for latentmycobacterium tuberculosis despite her negative QFTB test.She was treated with brief courses of doxycycline andminocycline separately which did not relieve her lowerextremity aching. Her clinical condition worsened with yellowdischarge, tenderness, erythema and ulceration whichprompted a skin biopsy from her left leg. The histopathologyshowed an ulcer with superficial granulation tissue and dermalfibrosis which extended to the fat. Acid-fast bacilli wereidentified at 8 weeks and Mycobacterium poriferae wasidentified by DNA sequencing at 12 weeks. At this stage shehad completed 9 months of anti-tuberculous therapy.
The woman was then treated with clarithromycin andciprofloxacin. Her treatment was then changed fromclarithromycin to azithromycin due to nausea. Also at thisstage, she was started on treatment with ustekinumab, a non-TNF-α biologic agent. After 6 months, her leg eruption hadimproved significantly and after a total of 9 months onciprofloxacin and azithromycin, it cleared. Two months aftercompleting anti-microbial therapy, her papulopustulareruption was completely resolved. Her psoriasis was well-controlled with ustekinumab.
Author comment: "Infections with non-tuberculousmycobacteria (NTM) have become more prevalent in theimmunosuppressed population...All three of the commonlyused anti-TNF-α therapies are linked to these infections."Laquer VT, et al. Mycobacterium porferae infection in a psoriasis patient on anti-tnf-a therapy. Dermatology Online Journal 19: No. 9, Sep 2013 - USA 803096180
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Reactions 30 Nov 2013 No. 14800114-9954/13/1480-0001/$14.95 Adis © 2013 Springer International Publishing AG. All rights reserved
