Anti-TNF therapy has revolutionized the treatment of various autoimmune conditions. However, it has also been associated with an increased risk of bacterial infections. To our knowledge, no case of Acinetobacter baumannii bacteremia has been reported with adalimumab treatment.

A 63-year-old female with generalized pustular psoriasis (GPP) was referred to the ED by her dermatologist for worsening rash, severe weakness, and fatigue. Symptoms began a week prior and acutely worsened after adalimumab infusion a day before hospital presentation. This was her second infusion, the first had been two weeks earlier. In the ED, her vital signs and labs were unremarkable. However, she had chills, prompting the collection of two blood cultures at different sites, which were both positive for A. baumannii. She had no clear infection source. Infectious disease (ID) was consulted, and she was started on ampicillin-sulbactam. Her weakness and fatigue improved shortly after starting antibiotics. A transthoracic echocardiogram showed no vegetations, and repeat blood cultures were negative. Dermatology attributed her worsening rash to a GPP flare, and spesolimab was recommended. Her medical records showed a positive Quantiferon-TB Gold, with a low mitogen-nil value and a chest X-ray showing no evidence of past or current tuberculosis infection. ID suggested the result was a false positive, but a subsequent positive T-spot confirmed latent tuberculosis. Biologic treatment was suspended until completing one month of latent tuberculosis treatment. Outpatient ID planned to initiate once-weekly isoniazid plus rifapentine. Meanwhile, acitretin was started, with dermatology follow-up scheduled for one month later to begin spesolimab after latent tuberculosis treatment. She was discharged on ciprofloxacin to complete her antibiotic course.

Acinetobacter baumannii, part of the ESKAPE organisms, is predominantly associated with healthcare-related infections and known for developing antibiotic-resistant strains. In the US, community-acquired A. baumannii cases are rare, with most being hospital-acquired infections. Moreover, shaking chills is an independent predictor of bloodstream infection. Given that blood is generally sterile, there is a low likelihood it was a contaminant. This case highlights the importance of clinical exam findings to maintain a high index of suspicion for severe infections such as bacteremia in immunocompromised individuals, and the necessity for physicians to broaden differentials to include rare organisms even in the absence of recent clinical exposure. Fortunately, the isolate was pan-sensitive, as multidrug-resistant A. baumannii infections can be life-threatening. Additionally, we are not suggesting that the patient's symptoms were solely due to bacteremia; reactivation of latent tuberculosis may have contributed.