Non-Tuberculous Mycobacteria (NTM) infections are increasingly concerning due to their rising prevalence and antibiotic resistance. NTM-PD, primarily caused by Mycobacterium avium complex (MAC), has been linked to a variety of environmental exposures, with water and soil as common sources. Known risk factors include structural lung abnormalities such as bronchiectasis, chronic obstructive pulmonary disease (COPD), and immune-compromised conditions. However, some cases lack these typical risk factors, suggesting the need for further investigation into the pathophysiology of NTM infections.
This case report introduces a unique scenario where a patient receiving Secukinumab for psoriasis developed recurrent NTM-PD. Although previous research has indicated a low risk of Mycobacterium tuberculosis infection with Secukinumab, this report highlights its potential role in the recurrence of NTM infections, a phenomenon not previously reported.
Case Presentation
A 48-year-old female with a history of plaque psoriasis presented with chronic cough and chest tightness. Her medical history included chronic hepatitis B, lumbar disc herniation, and no previous tuberculosis or pneumonia. In 2020, she was diagnosed with bronchiectasis (BE) after experiencing persistent cough, yellow sputum, and hemoptysis. Initial treatment with antibiotics provided temporary relief but did not resolve the symptoms. By May 2021, her symptoms worsened, and chest CT scans indicated new signs of infectious bronchiolitis.
During her hospitalization, a bronchoscopy and metagenomic next-generation sequencing (mNGS) of bronchoalveolar lavage fluid (BALF) confirmed the presence of MAC. The patient was treated with a combination of Azithromycin, Ethambutol, and Rifampicin. Despite adherence to treatment and avoiding hot springs, her condition relapsed after 20 months. Subsequent cultures from August 2023 confirmed MAC infection.
The patient had been receiving Secukinumab injections for psoriasis since 2019, and despite discontinuing NTM treatment in March 2023, her condition relapsed with hemoptysis and MAC reemergence by October 2023. In December 2023, sputum tests ruled out drug-resistant strains, and by February 2024, treatment with standard NTM therapy and nebulized Amikacin was initiated. Follow-up sputum cultures in June 2024 indicated the presence of Mycobacterium abscessus, prompting a change in therapy.
Outcome and Follow-Up
The patient’s treatment regimen was adjusted to include Rifampicin, Ethambutol, Azithromycin, Omadacycline, and Amikacin. After three months, follow-up imaging showed partial absorption of pulmonary lesions, though new lesions were observed. The patient was also started on immunomodulatory therapy with Mycobacterium w (Mw) vaccine and Cordyceps sinensis. A subsequent chest CT in December 2024 revealed significant absorption of lesions, and the patient continued regular follow-ups with a reduction in sputum production.
Discussion
The relationship between Secukinumab and NTM-PD is underexplored, with only rare reports of mycobacterial infections, including tuberculosis and NTM uveitis, in patients using this drug. This case suggests that Secukinumab, a potent IL-17A inhibitor, may increase susceptibility to NTM infections, especially when combined with environmental exposures like hot springs. The patient’s recurrent infection, despite strict adherence to NTM treatment and avoidance of hot springs, supports the hypothesis of an immunosuppressive effect of Secukinumab contributing to NTM recurrence.
The interplay between bronchiectasis (BE) and NTM-PD is complex, with BE both a potential consequence and risk factor for NTM infection. In this case, the initial MAC infection may have contributed to the development of BE, complicating the patient’s treatment. The use of immunosuppressive therapies like Secukinumab has been linked to an increased risk of infections, including NTM, further emphasizing the need for careful monitoring in patients undergoing such treatments.
Conclusion
This case highlights the potential risk of recurrent NTM-PD in patients treated with Secukinumab for psoriasis. Clinicians should be vigilant in monitoring for NTM infections, particularly in patients with prolonged immunosuppressive therapy. Further research is needed to better understand the mechanisms underlying the association between IL-17A inhibitors and NTM disease.
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