Atypical oral candidiasis in a psoriatic patient during targeted immunotherapy with an interleukin 17 inhibitor (secukinumab)

Abstract

Background Secukinumab is a human monoclonal antibody immunoglobulin that neutralises interleukin (IL)-17A, and as such, is effective in the treatment of psoriasis. However, as IL-17A is essential in protection against fungal infections, patients treated with this drug may develop candidiasis. This report presents a case of atypical oral candidiasis occurring during targeted drug immunotherapy with an interleukin 17 (IL-17) inhibitor (secukinumab), with the aim of emphasisinge the necessity of periodical oral health assessment and monitoring. It provides a rational clinical approach to therapeutic protocol in the treatment of side effects associated with novel medications for autoimmune diseases. Case presentation Symptomatic tongue lesions were observed in a 50-year-old female patient on a monthly systemic treatment of 300 mg of secukinumab, which appeared after 60 days of using the medication. Two inconclusive biopsies and an unsuccessful application of oral corticosteroids made the diagnostic process challenging. Papillae on the back of the tongue were atrophied, forming a well-defined erythema and white non-detachable plaques on the lateral border of the tongue. Cytopathological and histopathological exam results were compatible with a diagnosis of oral candidiasis. Topical antifungal medication led to subsequent regression of the tongue lesions. During asymptomatic period and follow up for 7 months, a reduced monthly dose 150 mg of secukinumab was administered. Conclusions Patients undergoing treatment with IL-17 blockers, such as secukinumab, should be carefully monitored in order to avoid oral side effects resulting from the use of this medication.

Oral Candida Infection in Psoriatic Patients Treated with IL17A Inhibitors: Report of 3 Cases and a Comprehensive Review of the Literature

“…Overall, it appears that the majority of aforementioned OC cases, including ours, affected the tongue, followed by the buccal and palatal mucosa and the commissures. In particular, a clinical presentation of CHC, i.e., a non-detachable (or only partially removable) white plaque, appears to be common [ 58 , 60 ], similar to our case #1, while a co-existence of oral lichenoid lesions is also possible [ 27 , 60 , 61 ]. This propensity for relatively unusual or atypical clinical features, compared to the more typical pseudomembranous or erythematous OC, necessitates ruling out other conditions with clinical similarities.…”

“…Besides clinical trials, the number of case series and reports specifically addressing the development of OC in patients receiving anti-IL17A regimens remains very limited [ 27 , 58 , 59 , 60 , 61 , 62 ]. In this regard, our three cases represent uncommonly reported examples of microscopically proven OC with the characteristic clinical appearance in patients without any other predisposing factor besides anti-IL17A treatment, while case #3 is the first well-documented OC related to brodalumab published to this date.…”

“…Interestingly, in addition to CHC, the patient also presented with asymptomatic oral lichenoid lesions (not biopsy-proven), which were also attributed to secukinumab, although a clear correlation with the onset of the medication could not be supported. Picciani et al [ 58 ] reported a similar case of a 50-year-old psoriatic female patient on secukinumab (300 mg monthly), who also presented OC involving the tongue in the form of erythema and atrophy of the dorsal surface and non-removable white plaques on the lateral border; the lesions developed 60 days after commencement of the antipsoriatic medication. A suitable response was achieved with topical application of miconazole oral gel 20 mg qid for 30 days, and the patient was recommended to discontinue the antipsoriatic treatment.…”

“…In relation to the possible need for drug discontinuation, it seems that OC does not necessarily constitute a reason to discontinue the anti-IL17A inhibitors, as in the case reported by Farah [ 60 ]. However, in the other four reported cases [ 27 , 58 , 61 , 62 ], discontinuation of the treatment was elected, followed by adjustment of the dosage [ 58 ] or replacement of the medication with other of the same [ 27 ] or other class [ 62 ].…”

A Comparative and Comprehensive Review of Antibody Applications in the Treatment of Lung Disease

“…However, either of these approaches has the potential to slow cancer growth [87]. Furthermore, IL-17 inhibitors such as secukinumab have already been shown to be effective [88]. In a case report, a patient with LUAD developed psoriasis as a result of the administration of pembrolizumab.…”