Mycobacterium chelonae infection associated with adalimumab therapy

Infectious Complications of Biological and Small Molecule Targeted Immunomodulatory Therapies

The past 2 decades have seen a revolution in our approach to therapeutic immunosuppression. We have moved from relying on broadly active traditional medications, such as prednisolone or methotrexate, toward more specific agents that often target a single receptor, cytokine, or cell type, using monoclonal antibodies, fusion proteins, or targeted small molecules. This change has transformed the treatment of many conditions, including rheumatoid arthritis, cancers, asthma, and inflammatory bowel disease, but along with the benefits have come risks. Contrary to the hope that these more specific agents would have minimal and predictable infectious sequelae, infectious complications have emerged as a major stumbling block for many of these agents. Furthermore, the growing number and complexity of available biologic agents makes it difficult for clinicians to maintain current knowledge, and most review articles focus on a particular target disease or class of agent. In this article, we review the current state of knowledge about infectious complications of biologic and small molecule immunomodulatory agents, aiming to create a single resource relevant to a broad range of clinicians and researchers. For each of 19 classes of agent, we discuss the mechanism of action, the risk and types of infectious complications, and recommendations for prevention of infection.

Mycobacterium chelonae cutaneous infection: An opportunistic disease in an immunosuppressed patient with myasthenia gravis

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Mycobacterium chelonae infection may occur in chronic treatment with steroids.

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The most common presentation form is disseminated cutaneous infection.

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First-line treatment should be a triple antibiotics association for at least 4 months.

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Macrolides, fluoroquinolones and other antibiotics may exacerbate myasthenia gravis.

Mycobacterium chelonae can cause chronic skin, soft-tissue or bone infections.

and is often associated with the immunocompromised state.We describe a case of a 58-year-old male patient with myasthenia gravis, chronically immunosuppressed, with a four month progression of growing erythematous, nodular and hard cutaneous lesions in the left forearm, leg and foot. He was receiving immunoglobulin every four weeks (2 g/kg) and prednisolone 25 mg/day and had an important previous history of several opportunistic infections while he was receiving corticosteroids.

Histopathological examination of a biopsy showed acid-fast bacilli and tissue culture identified a Mycobacterium spp. within seven days of incubation, with Mycobacterium chelonae being identified by polymerase chain reaction assay. Antimicrobial susceptibility testing was performed showing no resistance and the patient was successfully treated during four months with ciprofloxacin, clarithromycin and trimethoprim-sulfamethoxazole with regression of the lesions, leaving some hyperpigmentation scars and without unbalancing his neurological disease.

Patients with myasthenia gravis should be closely monitored because first line treatments for M. chelonae infection may be associated with myasthenic crisis.

Is continuation of anti-tumor necrosis factor-α therapy a safe option for patients who have developed pulmonary mycobacterial infection? : Case presentation and literature review

Continuation of anti-tumor necrosis factor-α (TNFα) therapy generally has not been recommended for patients who have developed nontuberculous mycobacterial (NTM) diseases; in daily practice, however, we often encounter patients with refractory rheumatoid arthritis (RA) who experience uncontrollable flares following withdrawal of anti-TNFα agents. Here, we report a case of pulmonary NTM disease caused by Mycobacterium intracellulare occurring in a patient with refractory RA undergoing etanercept therapy. Since there was the concern of an exacerbation of RA symptoms, etanercept was continued during anti-NTM therapy. The patient's pulmonary symptoms and radiological abnormalities were found to have markedly improved in a relatively short time period after beginning the anti-NTM therapy. Additionally, her RA symptoms were adequately controlled without the occurrence of any unexpected adverse events. The continuation of etanercept therapy may be a safe option during anti-NTM therapy if patients' underlying diseases would otherwise be difficult to control. Strictly supervised anti-NTM therapy and patients' informed consent are mandatory. We review the medical literature on NTM disease associated with anti-TNFα therapy for rheumatic diseases and discuss the safety of simultaneous use of anti-TNFα agents in patients during anti-NTM therapy.

Disseminated Mycobacterium chelonae infection in a patient receiving an epidermal growth factor receptor inhibitor for advanced head and neck cancer

We report a case of disseminated cutaneous Mycobacterium chelonae infection in a patient with head and neck cancer on salvage chemotherapy, including the epidermal growth factor receptor inhibitor cetuximab. Mycobacterium chelonae should be considered in the differential diagnosis of cutaneous infections in cancer patients receiving epidermal growth factor receptor inhibitors.

Mycobacterium marinum infection complicated by anti-tumour necrosis factor therapy

Mycobacteria other than tuberculosis infections in patients taking various tumour necrosis factor (TNF)-α inhibitors have been reported in the literature. We describe sporotrichoid spread of Mycobacterium marinum in a man with Crohn's disease treated with infliximab. After starting ethambutol and rifampicin and discontinuing infliximab, a worsening appeared. M. marinum infection may have a potential local spread and systemic dissemination in patients treated with TNF-α inhibitors.

[Cutaneous infection due to Mycobacterium chelonae during anti-TNF therapy]

BACKGROUND

Mycobacterium chelonae is a ubiquitous, rapidly growing, opportunistic, non-tuberculous mycobacterium that can cause skin and bone tissue infections. We report a case of cutaneous infection due to M. chelonae following anti-TNF therapy.

CASE REPORT

A 70-year-old woman with a medical history of rheumatoid arthritis was admitted for several purple nodular cutaneous lesions on her right leg evolving for 2 months. At admission, she was on prednisone, methotrexate and adalimumab for her rheumatoid arthritis. Skin lesions appeared 5 days before etanercept, which was taken for 5 months before being discontinued for adalimumab. Both the histopathological examination and bacterial culture of involved skin showed the presence of M. chelonae. Adalimumab was immediately discontinued and a combination of amoxicillin-clavulanic acid and tigecyclin was started.

DISCUSSION

TNF-alpha plays a pivotal role in immune reaction to intracellular pathogens. Very few cases of cutaneous infection involving M. chelonae in association with an anti-TNF-alpha therapy have been reported in the literature. To our knowledge, this is the first case occurring during treatment with etanercept and symptoms worsened with the introduction of adalimumab. In addition, this case underlines the difficulties of effectively treating this mycobacterium.