A case of nocardiosis in a patient with ulcerative colitis on chronic corticosteroids, infliximab, and upadacitinib

by Selleckchem | Jul 21 2023

Key clinical message: Immunosuppression, malnutrition, and underlying infection can unmask obscure infections which can be challenging to identify. Early diagnosis and treatment of infections in immunosuppressed patients are essential due to high morbidity and mortality.

Abstract: The immunosuppressive effects of treatment for ulcerative colitis (UC), including chronic corticosteroids, anti-TNF agents, and JAK inhibitors, can impact the spread of latent or obscure infections. Clinicians should have a low threshold for pursuing aggressive diagnostic and therapeutic intervention in patients who show signs of clinical deterioration while on immunosuppressing medications. Our unique case highlights an immunosuppressed patient with UC who developed Nocardiosis after initiation of upadacitinib while hospitalized for concurrent UC flare and Clostridium difficile infection.

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Title: Immunosuppression Unveils Obscure Infections: A Challenging Diagnostic Dilemma in Ulcerative Colitis Patients

Introduction: Immunosuppression, malnutrition, and underlying infections pose a significant risk for immunocompromised individuals, especially in patients with ulcerative colitis (UC). The administration of immunosuppressive medications, such as chronic corticosteroids, anti-TNF agents, and JAK inhibitors, can disrupt the delicate balance of host defense mechanisms, leading to the unmasking of latent or obscure infections. This case report emphasizes the importance of early identification and prompt management of infections in immunosuppressed patients, as delayed diagnosis can contribute to increased morbidity and mortality rates.

Case Presentation: We present a unique case of a patient with UC who experienced clinical deterioration after initiation of upadacitinib, a JAK inhibitor, during hospitalization for a concurrent UC flare and Clostridium difficile infection. The patient, previously stable on immunosuppressive therapy, developed Nocardiosis, an uncommon but potentially life-threatening infection, which had been latent prior to the immunosuppressive treatment.

Discussion: Immunosuppressive agents commonly used in the management of UC, such as corticosteroids, anti-TNF agents, and JAK inhibitors, can impair the immune response, increasing the risk of infectious complications. In this case, the introduction of upadacitinib further compromised the patient's immune system, allowing the latent Nocardia infection to flourish. The combination of immunosuppression, malnutrition, and underlying infection created a challenging diagnostic dilemma, as the clinical presentation mimicked the exacerbation of UC symptoms.

Clinicians caring for immunosuppressed UC patients should maintain a high index of suspicion for underlying infections, particularly when patients show signs of clinical deterioration despite ongoing therapy. Timely and accurate diagnosis is crucial, as delayed recognition can lead to worsening infection and poor outcomes. Aggressive diagnostic strategies, including imaging studies, serological tests, and tissue biopsies, should be pursued when suspicion of an underlying infection arises.

Conclusion: This case highlights the importance of vigilance and proactive management of infections in immunosuppressed UC patients. Early diagnosis and prompt initiation of appropriate antimicrobial therapy are crucial to mitigate the morbidity and mortality associated with obscure infections unmasked by immunosuppressive treatment. Clinicians should maintain a low threshold for pursuing aggressive diagnostic interventions in this vulnerable patient population to ensure optimal patient outcomes and minimize potential complications.