Adalimumab (Humira®) Induced Recurrent Peritonsillar Abscess in A Patient Received Three Different Anti-TNF Therapies: A Case Report

The most common bacterium isolated in PTA are Streptococcus and Fusobacterium, but many abscesses have a mixed profile [2, 3]. Primary treatment strategies are the initiation of appropriate antibiotic therapy and percutaneous evacuation of the abscess if needed. “Recurrence” term for PTA can be defined as a new episode of PTA in ≥ 30 days from the initial PTA [4]. The frequency of recurrent PTA in the normal population is 5.15-16%, and even much higher in younger populations aged 13–18 [5, 6]. As early recurrence can be linked to inadequate treatment, extra-peritonsillar spread of infection, or autoimmune deficiency, late recurrence is more likely related to autoimmune deficiency or prior history of tonsillitis or pharyngitis [6]. Unfortunately, the literature does not answer to the question, “How many times can a PTA recur.” Our patient with AS receiving anti-TNF treatment had recurrent PTA attacks (four times), requiring surgical interventions and hospitalizations (two times) in the two-year time period. Although his anti-TNF regimen was the usual suspect, neither the patient himself stated his emergency visits or interventions to his rheumatologist during his follow-up, nor was there any executed rheumatology referral or consultation. Since none of PTAs accompanied by tonsillitis, tonsillectomy was not considered. In addition, the microorganisms causing PTAs were not determined because no culture study was performed. The large-scale studies on the relationship between anti-TNF and infection focused predominantly on tuberculosis activation and opportunistic infections [7, 8]. We could not be sure if PTA episodes were related to any opportunistic microorganism since no culture study was conducted.

As we assume that his repetitive medical condition was associated with the anti-TNF agent, we investigated the drug regimens he received. He had used etanercept and infliximab, and he has been treated with adalimumab for the last five years. All three are the most commonly used anti-TNF agents. He had four PTA during active use of adalimumab. However, the findings comparing the risk of infection in patients treated with etanercept, adalimumab, and infliximab showed no significant difference between the three drugs [9]. In a meta-analysis, significant increases were found in anti-TNF drug use by 20% for any infection, 40% for severe infection, and 250% for tuberculosis reactivation [7]. Nevertheless, we did not encounter any reports or studies including or specifically addressing PTA under anti-TNF treatment.

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