Staphylococcus aureus bacteremia with iliac artery endarteritis in a patient receiving ustekinumab

Abstract

BackgroundUstekinumab (Stelara®), a human monoclonal antibody targeting the p40-subunit of interleukin (IL)-12 and IL-23, is indicated for moderate to severe plaque psoriasis and psoriatic arthritis. In large multicenter, prospective trials assessing efficacy and safety of ustekinumab increased rates of severe infections have not been observed so far.Case presentationHere, we report the case of a 64-year old woman presenting with chills, pain and swelling of her right foot with dark maculae at the sole, and elevated inflammatory markers. She had received a third dose of ustekinumab due to psoriatic arthritis three days before admission. Blood cultures revealed growth of Staphylococcus aureus and imaging showed a thickening of the aortic wall ventral the bifurcation above the right internal iliac artery, resembling an acute bacterial endarteritis. Without the evidence of aneurysms and in absence of foreign bodies, the decision for conservative management was made. The patient received four weeks of antibiotic therapy with intravenous flucloxacillin, followed by an oral regime with levofloxacin and rifampicin for an additional four weeks. Inflammatory markers resolved promptly and the patient was discharged in good health.ConclusionTo our knowledge, this is the first report of a severe S. aureus infection in a patient receiving ustekinumab. Albeit ustekinumab is generally regarded as a safe drug, severe bacterial infections should always be included in the differential diagnosis of elevated inflammatory markers in patients receiving biologicals as these might present with nonspecific symptoms and fever might be absent. Any effort to detect deep-seated or metastatic infections should be made to prevent complications and to secure appropriate treatment. Although other risk factors for an invasive staphylococcal infection like psoriasis, recent corticosteroid injection, or prior hospitalisations were present, and therefore a directive causative link between the S. aureus bacteraemia and ustekinumab can not be drawn, we considered the reporting of this case worthwhile to alert clinicians as we believe that ongoing pharmacovigilance to detect increased risks for rare but severe infections beyond phase II and phase III trials in patients treated with biologicals is essential.

Global Risk of Bacterial Skin Infections and Herpesviridae Infections with Ustekinumab, Secukinumab, and Tumour Necrosis Factor-alpha Inhibitors: Spontaneous Reports of Adverse Drug Reactions from the World Health Organization Pharmacovigilance Center

“…To date, clinical trials have not reported an increased risk of bacterial skin infections in secukinumab and ustekinumab users ( 27 , 28 ). A single case report has described the occurrence of S. aureus bacteraemia with iliac artery endarteritis after the third dose of ustekinumab ( 14 ). Only a few case reports have been published on bacterial skin infections during TNF-α inhibitor therapy ( 29 , 30 ).…”

“…For ustekinumab, multiple cases of bacterial skin infections and Herpesviridae infections have been described in clinical trials and case reports (13)(14)(15). Herpesviridae infections were seen more frequently during the first 12 weeks of treatment with secukinumab compared with etanercept (16).…”

Розвиток Імунної Відповіді При Стафілококовій Пневмонії (Частина 3)

“…Во время стафилококковой инфекции интерлей-кин 1β (interleukin-1β -IL-1β) в основном способ-ствует привлечению нейтрофилов в очаг поражения [19,48]. Интерлейкин IL-1β, взаимодействуя с ре-цептором IL-1R многочисленных типов иммуно-цитов, активирует внутриклеточный MyD88/IRAK/ …”

Psoriasis: To Vaccinate or Not to Vaccinate?

“…The levels of these cytokines, along with others derived from TH 17 cells, in skin lesions as well as in peripheral blood have been shown to be elevated in psoriasis patients as compared to their healthy counterparts [ 5 ]. IL-17 has also been shown to act on dermal fibroblasts in stromal tissue leading to the production of pro-inflammatory cytokines that promote the expression of keratin 17, which is the only keratin that has been found in the lesions of psoriasis patients [ 6 ].…”