2019 Research Forum

Applicant: Carlos D’Assumpcao MD R1 Principal Investigator & Faculty Sponsor: Arash Heidari MD

First Reported Case of Malignant Otitis Externa Secondary to Treatment with Secukinumab

Golriz Asefi MD Graduate RA, Carlos D’Assumpcao MD R1, Ramanjeet Sidhu MD R3, Arash Heidari MD

INTRODUCTION Secukinumab is a fully humanized monoclonal antibody that selectively inhibits interleukin (IL) 17A, and has been approved for the treatment of autoimmune disorders that arise from dysregulation of this IL such as psoriasis. However, inhibition of IL17A is associated with increased incidents of nasopharyngitis, upper respiratory and mucocutaneous infections (28.7% vs. 18.9% placebo).

PURPOSE We are presenting the first reported case of malignant otitis externa associated with the treatment of psoriasis using Secukinumab. HIPAA/IRB review and approval for the case report was obtained.

DISCUSSION A 38-year-old non-diabetic male with cutaneous and psoriatic arthritis suppressed with Secukinumab presented to Kern Medical with a five-day history of unilateral ear pain, discharge, swelling, numbness of cheek and hearing loss. Outpatient oral and otic ciprofloxacin had not improved his symptoms. Upon admission, he had no fever and was found to have periauricular and postauricular erythema and tenderness consistent with malignant otitis picture. On otoscopy, a ruptured right tympanic membrane and whitish discharge were visualized. His WBC was 12.4 u/L without a left shift. CT scan showed opacification of the middle ear cavity, external auditory canal with superficial soft tissue component and involvement of mastoids. ENT service did not agree with the presence of mastoiditis and no interventions were recommended. He was placed on broad-spectrum antibiotics with vancomycin, piperacillin/tazobactam and otic ciprofloxacin, to cover pathogens associated with malignant otitis externa. Gram stain from the ear canal was consistent with gram positives and gram negatives. Subsequently, the culture grew Streptococcus agalactiae and Pseudomonas aeruginosa. His symptoms started to improve with resolution of the pain, swelling, and discharge and improvement of hearing loss. His antibiotics were de-escalated to levofloxacin 750 mg daily based on sensitivities, and he was later discharged home to finish a 14-day course of treatment. He was instructed to hold Secukinumab.

Secukinumab was resumed six months later at patient’s insistence, and 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 biosimilar agents.

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