Recurrent NTM Pulmonary Disease in Plaque Psoriasis Patient on Secukinumab: A Case Study on Diagnosis and Relapse

A Journey Through Diagnosis and Relapse: Navigating Non-Tuberculous Mycobacterial Disease

In June 2021, a 48-year-old woman arrived at the hospital with a persistent cough that had lingered for a year and a half, accompanied by worsening chest tightness over the past month. Her medical history included chronic hepatitis B and lumbar disc herniation, but she had no record of childhood pneumonia, measles, or tuberculosis.

Her symptoms began in early 2020, marked by a continuous cough with yellow sputum, occasional hemoptysis, and no signs of fever, night sweats, or breathing difficulties. Initially, she sought treatment at a tertiary hospital in May 2020, where she was diagnosed with bronchiectasis (BE). Antibiotics provided temporary relief, but her symptoms—cough, sputum production, and hemoptysis—returned intermittently. Repeated chest CT scans confirmed BE with chronic inflammation, and treatments with cephalosporins and levofloxacin offered only short-term improvement.

By May 2021, her condition worsened, with increased chest tightness and fatigue. A new chest CT revealed mild thickening of the bronchial wall, multiple small centrilobular nodules (a "tree-in-bud" sign), and new infiltrates in the right upper lobe. Suspecting an underlying cause beyond BE, doctors referred her for further evaluation.

The patient, who had no history of smoking or alcohol use, shared a unique detail: she had been swimming daily in unchlorinated hot spring water for years. This raised concerns about potential exposure to environmental pathogens. Upon discharge, she was advised to avoid hot springs and begin treatment for non-tuberculous mycobacterial (NTM) disease, including daily doses of azithromycin, ethambutol hydrochloride, and rifampicin.

However, her journey didn’t end there. In October 2023, she returned to the clinic with a history of plaque psoriasis, diagnosed in 2014. Her skin condition had been managed with vitamin D3 ointments until symptoms worsened, prompting her to start secukinumab injections in July 2019. By 2023, she was receiving these injections every four to five months. Despite her NTM diagnosis, she had not pursued treatment due to personal reasons.

That October, she experienced another episode of hemoptysis, expectorating two teaspoons of blood. By December 2023, sputum samples were collected for molecular drug susceptibility testing, which ruled out common drug-resistant genes.

In February 2024, her plaque psoriasis flared again, leading her to the dermatology department for another secukinumab injection. Throughout this period, her chest CT scans showed fluctuating patterns of bronchial wall thickening, exudation, and nodules, reflecting the chronic and relapsing nature of her condition.

Her story underscores the complexities of managing NTM disease, particularly in patients with coexisting conditions like psoriasis. It highlights the importance of consistent treatment, environmental precautions, and multidisciplinary care in navigating such challenging diagnoses.

Conclusion

The ‌journey of ‍this 48-year-old woman through the complexities ⁢of non-tuberculous ​mycobacterial (NTM) ⁣disease underscores the challenges of‍ diagnosing and managing ‍this ⁢often-overlooked condition. ‍Her persistent symptoms, initially mistaken for more common respiratory‍ ailments, highlight the importance of considering ‌NTM in patients ‌with ​chronic cough and atypical presentations, ⁣particularly when standard⁣ treatments fail to yield enhancement.

Her case also emphasizes the critical role of multidisciplinary⁢ care⁣ in navigating NTM disease. From accurate diagnosis through advanced ​imaging and microbiological testing ‍to the careful selection⁣ of ⁤antimicrobial therapy, each step requires precision and collaboration among ⁢healthcare providers. Moreover, her experience ​with relapse serves as a reminder⁣ of the​ disease’s insidious nature and the need for vigilant, long-term monitoring to prevent recurrence.

As NTM infections continue to rise globally, this case reinforces the necessity of raising‍ awareness among clinicians⁢ and patients alike. ⁣Early recognition, tailored treatment plans, and patient education are essential‍ to improving outcomes for those affected‍ by this challenging condition. By sharing stories like hers, we can foster a deeper understanding of NTM disease ⁣and ​pave ‍the way for more effective management strategies, ultimately⁣ enhancing ​the quality of​ life for patients navigating this difficult journey.
Conclusion

the journey of this 48-year-old woman through the complexities of non-tuberculous mycobacterial (NTM) disease underscores the challenges of diagnosing and managing chronic, relapsing conditions. Her case highlights the intricate interplay between environmental exposures, underlying health conditions, and the limitations of standard treatments. The persistent nature of her symptoms,coupled with the delayed diagnosis of NTM,emphasizes the importance of considering atypical pathogens in patients with recurrent respiratory infections,especially when conventional therapies fail to provide lasting relief.

Her history of swimming in unchlorinated hot spring water serves as a critical reminder of the potential risks associated with environmental reservoirs of NTM. This case also illustrates the delicate balance required when managing comorbid conditions, such as plaque psoriasis, which necessitated immunosuppressive therapy that may have exacerbated her susceptibility to infections.

As the medical community continues to grapple with the rising prevalence of NTM disease, this patient’s story underscores the need for heightened awareness, timely diagnostic interventions, and personalized treatment strategies. It also calls for further research into the environmental and immunological factors that contribute to NTM infections, as well as the development of more effective therapies to prevent relapse and improve long-term outcomes.

Ultimately, her journey is a testament to the resilience of patients navigating chronic illnesses and the importance of a multidisciplinary approach to care. By addressing the unique challenges posed by NTM disease, healthcare providers can better support patients in achieving sustained recovery and an improved quality of life.