Case Report: A Patient on Apremilast Develops Streptococcus Salivarius

Bottom Line

It is likely the combination of a structurally abnormal valve and immunosuppression made the patient susceptible to valvular infection with an opportunistic organism. Infective endocarditis has severe morbidity and mortality. In the U.S. between 1980 and 2014, the mortality rate for endocarditis was 2.4 per 100,000 with an in-hospital mortality rate of around 20%.¹⁹ Contrary to previous thought, the decrease in pro-inflammatory mediators TNFα, IL-17 and IL-23 with apremilast may create immunosuppressant effects. These effects can have severe adverse outcomes, as in our patient. Caution should be used and further studies should be performed in this area. 

Stephanie Kydd Dondero, DO, is the chief fellow of the rheumatology program at Larkin Community Hospital/Lake Erie College of Osteopathic Medicine (LECOM), Miami.

Barry Waters, MD, has been in private practice in rheumatology in South Florida since 1986. For the past several years, he has served as the Rheumatology Fellowship program director for Larkin Community Hospital, Miami.

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