2019 Research Forum

Golriz Asefi MD Graduate RA, Carlos D’Assumpcao MD R1, Ramanjeet Sidhu MD R3, Arash Heidari MD Department of Medicine Kern Medical First Reported Case of Malignant External Otitis Secondary to Secukinumab

Introduction

Case Presentation

Hospital Course

38-year old white male with psoriasis • Prior treatment: etanercept, methotrexate, and meloxicam • Secukinumab for 8 months • 5-day history of right sided ear pain, discharge, swelling, numbness of the cheek, and hearing loss. • Outpatient oral and otic ciprofloxacin were ineffective Physical Exam • Afebrile • Periauricular and postauricular erythema and tenderness • Ruptured right tympanic membrane and purulent discharge • WBC was 12.4 u/L without a left shift Imaging • Opacification of the right middle ear cavity and external auditory canal • Superficial soft tissue and mastoid involvement

Secukinumab (Brand name Cosentyx) • Fully humanized monoclonal antibody that selectively inhibits interleukin (IL) 17A • FDA approved for the treatment of psoriasis • Secukimumab is associated with increased incidence of infection (28.7% vs 18.9% placebo) IL-17A and Psoriasis • Proinflammatory cytokine produced by activated T helper 17 cells (Th17)

Empiric antibiotic choice: • Vancomycin • Piperacillin/tazobactam • Otic ciprofloxacin

There was resolution of pain, swelling, and discharge, and improvement of hearing. Gram stain

• Gram positives cocci • Gram negatives rods Cultures • Streptococcus agalactiae • Pseudomonas aeruginosa

Outcome

• Levofloxacin 750 mg po daily for 14 days • Discharged home to finish antibiotic course • Secukinumab was held • Secukinumab was resumed six months later at patient's insistence • He subsequently suffered from a perirectal cellulitis. Conclusion Clinicians should be aware of the balance between suppression of autoimmune disorders and increase risk of serious infections using Secukinumab or other biologic agents. References Jordan CT, Cao L, Roberson ED, et al. (April 2012). "Rare and common variants in CARD14, encoding an epidermal regulator of NF-kappaB, in psoriasis". The American Journal of Human Genetics. 90: 796–808. Mudigonda P, Mudigonda T, Feneran AN, Alamdari HS, Sandoval L, Feldman SR (October 2012). "Interleukin-23 and interleukin- 17: importance in pathogenesis and therapy of psoriasis". Dermatol Online J. 18 (10): 1. Onishi RM, Gaffen SL. Interleukin-17 and its target genes: mechanisms of interleukin-17 function in disease. Immunology. 2010;129(3):311-21. Ouyang W (December 2010). "Distinct roles of IL-22 in human psoriasis and inflammatory bowel disease". Cytokine Growth Factor Rev. 21 (6): 435–41.

Biologic and associated opportunistic infections

Secukinumab TB reactivation, nasopharyngitis, herpes, pharyngitis, URI, pneumonia

Certolizumab TB reactivation, HBV reactivation, flu, life threatening bacterial, viral infections, fungal infections Infliximab TB reactivation, HBV reactivation, flu, life threatening bacterial, viral infections, fungal infections Adalimumab TB reactivation, HBV reactivation, flu, life threatening bacterial, viral infections, fungal infections Anakinra Life threatening infections, nasopharyngitis, sinusitis, otitis media, urinary tract infections, pneumonia Golimumab Life threatening infections, nasopharyngitis, sinusitis, otitis media, urinary tract infections, pneumonia Rituximab Toxic epidermal necrolysis, HBV reactivation, pneumonia, serious life threatening infections Etanercept Serious life threatening infections, TB reactivation, HBV reactivation, pneumonia,

Necrotizing (Malignant) External Otitis • An invasive infection of the external auditory canal and skull base • Elderly patients • Patients with diabetes mellitus This is a case of malignant external otitis associated with the use of Secukinumab in a non diabetic patient.

Life threatening infections, nasopharyngitis, sinusitis, otitis media, urinary tract infections, pneumonia

Abatacept

87