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Palacios-Diaz RD, Sahuquillo-Torralba A, Rocamora-Durán V, Unamuno-Bustos BD, Salavert-Lleti M, Santos-Alarcón S, Quintero A, Garcías-Ladaria J, Vila-Payeras A, Martínez-Doménech A, Mateu-Puchades A, Nadal-Lladó C, Botella-Estrada R. Klinisch-pathologische Eigenschaften kutaner und mukokutaner Leishmaniose bei mit TNF-α-Inhibitoren behandelten Patienten. J Dtsch Dermatol Ges 2023; 21:473-481. [PMID: 37183744 DOI: 10.1111/ddg.15007_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 01/03/2023] [Indexed: 05/16/2023]
Affiliation(s)
| | | | | | | | - Miguel Salavert-Lleti
- Infectious Diseases Department, Hospital Universitario y Politécnico La Fe, Valencia, Spanien
| | | | - Adriana Quintero
- Pathology Department, Hospital de Manacor, Illes Baleares, Spanien
| | - Joan Garcías-Ladaria
- Dermatology Department, Hospital Universitario Son Espases, Illes Baleares, Spanien
| | - Aina Vila-Payeras
- Dermatology Department, Hospital Universitario Son Llàtzer, Palma de Mallorca, Illes Baleares, Spanien
| | | | | | - Cristina Nadal-Lladó
- Dermatology Department, Hospital Universitario Son Llàtzer, Palma de Mallorca, Illes Baleares, Spanien
| | - Rafael Botella-Estrada
- Dermatology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spanien
- Department of Medicine, Universitat de València, Valencia, Spanien
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Martins LPA, Fukasawa JT, Messias MBBF, Castanho REP, Andrade LA, Sperança MA, Suzuki RB. Severe visceral leishmaniasis and COVID-19 coinfection in an immunosuppressed patient. Rev Inst Med Trop Sao Paulo 2022; 64:e21. [PMID: 35293559 PMCID: PMC8916590 DOI: 10.1590/s1678-9946202264021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/01/2022] [Indexed: 11/22/2022] Open
Abstract
Visceral leishmaniasis (VL) is an opportunistic disease in immunosuppressed individuals, who may present severe clinical conditions, such as the ones described in this patient. She lived in an endemic region for VL, and was possibly infected with L. (L.) infantum chagasi through the bite of a contaminated sand fly. This initial infection has triggered a pemphigus vulgaris condition by immunogenic proteins present in the mosquito's saliva. The immunosuppression caused by the use of high doses of corticosteroids to control the disease promoted a severe VL condition, with hepatosplenomegaly, thrombocytopenia and hemorrhages, requiring hospitalization and the onset of a subsequent SARS-CoV-2 infection. Due to the intensity of clinical manifestations related to VL, aggravated by COVID-19, she died two days after admission to the Clinical Hospital of Marilia Medical School (HC–Famema).
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Botana L, Ibarra-Meneses AV, Sanchez C, Matia B, San Martin JV, Moreno J, Carrillo E. Leishmaniasis: A new method for confirming cure and detecting asymptomatic infection in patients receiving immunosuppressive treatment for autoimmune disease. PLoS Negl Trop Dis 2021; 15:e0009662. [PMID: 34339445 PMCID: PMC8360552 DOI: 10.1371/journal.pntd.0009662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 08/12/2021] [Accepted: 07/19/2021] [Indexed: 11/19/2022] Open
Abstract
Visceral leishmaniasis (VL) in patients receiving immunosuppressant drugs for autoimmune disease has been on the rise. It is important—but difficult—to know when cure has been achieved in these patients since the withdrawal of immunosuppressants during antileishmania treatment is commonly required, and there is a risk of relapse when immunosuppression is restored. The prevalence of asymptomatic infection among those immunosuppressed for autoimmune disease is also uncertain. The present work describes how cytokine release assays can be used to confirm the cure of VL, and to determine the prevalence of asymptomatic infection, in such patients. After collection of blood from volunteers (n = 108), SLA-stimulation of peripheral blood mononuclear cell cultures and of whole blood was found to induce the production of different combinations of cytokines that served to confirm recovery from VL, and asymptomatic Leishmania infection. Indeed, cure was confirmed in 14 patients, all of whom showed a specific Th1 immune response against Leishmania, and the prevalence of asymptomatic infection was determined as 21.27%. Cytokine profiles could be used to manage VL in patients with autoimmune disease, and to identify and better protect those with asymptomatic infection who are at risk of developing this disease. Cytokine release assays were used to confirm the cure of visceral leishmaniasis in patients (from an area where Leishmania infantum is endemic) with autoimmune disease. They were also used to determine the prevalence of asymptomatic Leishmania infantum infection in similar patients. Some 21.27% of those with no clinical history of leishmaniasis were shown to have been contact with the parasite.
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Affiliation(s)
- Laura Botana
- WHO Collaborating Centre for Leishmaniasis, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda (Madrid), Spain
- Cardiology Department, Universidad Francisco de Vitoria/Hospital Ramón y Cajal Research Unit (IRYCIS), Madrid, Spain
| | - Ana Victoria Ibarra-Meneses
- WHO Collaborating Centre for Leishmaniasis, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda (Madrid), Spain
| | - Carmen Sanchez
- WHO Collaborating Centre for Leishmaniasis, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda (Madrid), Spain
| | - Belen Matia
- Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
| | | | - Javier Moreno
- WHO Collaborating Centre for Leishmaniasis, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda (Madrid), Spain
| | - Eugenia Carrillo
- WHO Collaborating Centre for Leishmaniasis, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda (Madrid), Spain
- * E-mail:
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Bosch-Nicolau P, Ubals M, Salvador F, Sánchez-Montalvá A, Aparicio G, Erra A, Martinez de Salazar P, Sulleiro E, Molina I. Leishmaniasis and tumor necrosis factor alpha antagonists in the Mediterranean basin. A switch in clinical expression. PLoS Negl Trop Dis 2019; 13:e0007708. [PMID: 31469834 PMCID: PMC6742442 DOI: 10.1371/journal.pntd.0007708] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 09/12/2019] [Accepted: 08/15/2019] [Indexed: 02/02/2023] Open
Abstract
Background Tumor necrosis factor alpha (TNF-α) blockers are recognized as a risk factor for reactivation of granulomatous infections. Leishmaniasis has been associated with the use of these drugs, although few cases have been reported. Methodology We performed a retrospective observational study including patients with confirmed leishmaniasis acquired in the Mediterranean basin that were under TNF-α blockers therapy at the moment of the diagnosis. Patients diagnosed in our hospital from 2008 to 2018 were included. Moreover, a systematic review of the literature was performed and cases fulfilling the inclusion criteria were also included. Principal findings Forty-nine patients were analyzed including nine cases from our series. Twenty-seven (55.1%) cases were male and median age was 55 years. Twenty-five (51%) patients were under infliximab treatment, 20 (40.8%) were receiving adalimumab, 2 (4.1%) etanercept, one (2%) golimumab and one (2%) a non-specified TNF-α blocker. Regarding clinical presentation, 28 (57.1%) presented as cutaneous leishmaniasis (CL), 16 (32.6%) as visceral leishmaniasis (VL) and 5 (10.2%) as mucocutaneous leishmaniasis (MCL). All VL and MCL patients were treated with systemic therapies. Among CL patients, 13 (46.4%) were treated with a systemic drug (11 received L-AmB, one intramuscular antimonials and one miltefosine) while 14 (50%) patients were given local treatment (13 received intralesional pentavalent antimonials, and one excisional surgery). TNF-α blockers were interrupted in 32 patients (65.3%). After treatment 5 patients (10.2%) relapsed. Four patients with a CL (3 initially treated with local therapy maintaining TNF-α blockers and one treated with miltefosine) and one patient with VL treated with L-AmB maintaining TNF-α blockers. Conclusions This data supports the assumption that the blockage of TNF-α modifies clinical expression of leishmaniasis in endemic population modulating the expression of the disease leading to atypical presentations. According to the cases reported, the best treatment strategy would be a systemic drug and the discontinuation of the TNF-α blockers therapy until clinical resolution. Tumor necrosis factor alpha (TNF-α) blockers are widely used in numerous inflammatory diseases such rheumatoid arthritis, psoriasis or inflammatory bowel diseases. They have been recognized as a risk factor for reactivation of granulomatous infections. Although few cases have been reported, Leishmaniasis has been associated with the use of these drugs. Leishmania infantum is the main causative agent of leishmaniasis in Southern Europe and is prone to produce the visceral form. However, TNF-α has been implicated in the initial events of the infection mediating the disease expression. In our series, we have observed a surprisingly high proportion of cutaneous form (32.6%) and muco-cutaneous form (10.2%). Clinical outcome observed in this series is also unusual. Four cases (14.3%) with cutaneous leishmaniasis who received local therapy relapsed. Among patients with visceral leishmaniasis, one patient who maintained TNF-α blockers therapy relapsed despite etiological treatment. This data supports the assumption that the blockage of TNF-α modifies clinical expression of leishmaniasis leading to atypical presentations. According to the cases reported we proposed as best treatment strategy a systemic drug and the discontinuation of the TNF-α blockers therapy until clinical resolution.
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Affiliation(s)
- Pau Bosch-Nicolau
- Department of Infectious Diseases, Hospital Universitari Vall d’Hebron, PROSICS Barcelona, Universitat Autònoma de Barcelona, Spain
| | - Maria Ubals
- Department of Dermatology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Spain
| | - Fernando Salvador
- Department of Infectious Diseases, Hospital Universitari Vall d’Hebron, PROSICS Barcelona, Universitat Autònoma de Barcelona, Spain
| | - Adrián Sánchez-Montalvá
- Department of Infectious Diseases, Hospital Universitari Vall d’Hebron, PROSICS Barcelona, Universitat Autònoma de Barcelona, Spain
| | - Gloria Aparicio
- Department of Dermatology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Spain
| | - Alba Erra
- Department of Rheumatology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Spain
| | - Pablo Martinez de Salazar
- Department of Clinical Microbiology, Hospital Universitari Vall d’Hebron, PROSICS Barcelona, Universitat Autònoma de Barcelona, Spain
| | - Elena Sulleiro
- Department of Clinical Microbiology, Hospital Universitari Vall d’Hebron, PROSICS Barcelona, Universitat Autònoma de Barcelona, Spain
| | - Israel Molina
- Department of Infectious Diseases, Hospital Universitari Vall d’Hebron, PROSICS Barcelona, Universitat Autònoma de Barcelona, Spain
- * E-mail:
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Autoantibodies in a Three-Year-Old Girl with Visceral Leishmaniasis: A Potential Diagnostic Pitfall. Case Rep Infect Dis 2016; 2016:2081616. [PMID: 27418985 PMCID: PMC4935904 DOI: 10.1155/2016/2081616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 05/23/2016] [Indexed: 11/30/2022] Open
Abstract
Visceral leishmaniasis (VL), a life-threatening parasitic infection, is endemic in the Mediterranean region. Diagnosis of VL is based on epidemiologic, clinical, and laboratory findings. However, sometimes, clinical features and laboratory findings overlap with those of autoimmune diseases. In some cases, autoantibodies are detected in patients with VL and this could be a potential diagnostic pitfall. In this study, we have reported on a three-year-old girl from a VL-endemic area in Iran, who presented with prolonged fever and splenomegaly. Bone marrow examination, serologic tests, and the molecular PCR assay were performed; however, results were inconclusive. The levels of anti-double stranded DNA, cytoplasmic antineutrophil cytoplasmic autoantibody, and perinuclear antineutrophil cytoplasmic autoantibody were elevated and, at the end, splenic biopsy was performed. The splenic tissue PCR test detected the DNA of Leishmania infantum. The patient's condition improved with anti-Leishmania therapy, and the autoantibodies disappeared within the following four months. Clinical presentations and laboratory findings of VL and autoimmune diseases may overlap in some patients.
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Downey C. Serious infection during etanercept, infliximab and adalimumab therapy for rheumatoid arthritis: A literature review. Int J Rheum Dis 2015. [DOI: 10.1111/1756-185x.12659] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Colum Downey
- Graduate Entry Medical School; University of Limerick; Limerick Ireland
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Català A, Roé E, Dalmau J, Pomar V, Muñoz C, Yelamos O, Puig L. Anti-Tumour Necrosis Factor-Induced Visceral and Cutaneous Leishmaniasis: Case Report and Review of the Literature. Dermatology 2015; 230:204-7. [DOI: 10.1159/000370238] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 12/01/2014] [Indexed: 11/19/2022] Open
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van Griensven J, Carrillo E, López-Vélez R, Lynen L, Moreno J. Leishmaniasis in immunosuppressed individuals. Clin Microbiol Infect 2014; 20:286-99. [DOI: 10.1111/1469-0691.12556] [Citation(s) in RCA: 227] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Guedes-Barbosa LS, Pereira da Costa I, Fernandes V, Henrique da Mota LM, de Menezes I, Aaron Scheinberg M. Leishmaniasis during anti-tumor necrosis factor therapy: report of 4 cases and review of the literature (additional 28 cases). Semin Arthritis Rheum 2013; 43:152-7. [PMID: 23777708 DOI: 10.1016/j.semarthrit.2013.01.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Revised: 01/30/2013] [Accepted: 01/31/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe the development of 4 new cases of leishmaniasis in patients receiving anti-tumor necrosis factor-α (anti-TNF) agents and review the pertinent literature. METHODS Chart review of the 4 cases and MEDLINE search for additional reported cases. RESULTS All reported cases, including ours, came from endemic areas. The infection was detected on an average of 23.5 months after the initiation of anti-TNF therapy. The majority of cases had the classical clinical presentation. The biological therapy was suspended in 21 cases. The results were successful for leishmaniasis therapy in all cases. In 10 cases it was possible to reintroduce anti-TNF agents. On follow-up it was observed that there was an infection relapse in 3 cases. CONCLUSIONS The present study shows that leishmaniasis, in its several clinical forms, should be included in the differential diagnosis of possible infections involving patients under use of aTNF therapy. Endemic disease under geographic expansion, easy international displacement and intense human migratory flows certainly represents a risk of this infection in an increasing universe of people which includes the immunosuppressed patients. Cutaneous lesions, prolonged fever, splenomegaly, and pancytopenias, the main clinical-laboratory findings of leishmaniasis, can also be present in autoimmune rheumatic disease, thus leading to delayed diagnosis and treatment of the parasitic disease. The diagnosis depends basically on a high suspicion index, being confirmed with the identification of the protozoan. The classic treatment of the infection when instituted is associated with complete recovery. It is important to point out that all cases reported so far had either originated from or been recently in regions regarded as endemic of leishmaniasis.
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Berry CE, Tsai J, Tierney A, Pickles R. Visceral leishmaniasis in a patient taking adalimumab for rheumatoid arthritis. Med J Aust 2013; 198:331-3. [DOI: 10.5694/mja12.11003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2012] [Accepted: 12/10/2012] [Indexed: 11/17/2022]
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Ali T, Kaitha S, Mahmood S, Ftesi A, Stone J, Bronze MS. Clinical use of anti-TNF therapy and increased risk of infections. Drug Healthc Patient Saf 2013; 5:79-99. [PMID: 23569399 PMCID: PMC3615849 DOI: 10.2147/dhps.s28801] [Citation(s) in RCA: 160] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Biologics such as antitumor necrosis factor (anti-TNF) drugs have emerged as important agents in the treatment of many chronic inflammatory diseases, especially in cases refractory to conventional treatment modalities. However, opportunistic infections have become a major safety concern in patients on anti-TNF therapy, and physicians who utilize these agents must understand the increased risks of infection. A literature review of the published data on the risk of bacterial, viral, fungal, and parasitic infections associated with anti-TNF therapy was performed and the clinical presentation, diagnostic tests, management, and prevention of opportunistic infections in patients receiving anti-TNF therapy were reviewed. Awareness of the therapeutic potential and associated adverse events is necessary for maximizing therapeutic benefits while minimizing adverse effects from anti-TNF treatments. Patients should be adequately vaccinated when possible and closely monitored for early signs of infection. When serious infections occur, withdrawal of anti-TNF therapy may be necessary until the infection has been identified and properly treated.
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Affiliation(s)
- Tauseef Ali
- OU Physicians Center for Inflammatory Bowel Disease, University of Oklahoma Health Sciences Center
- Department of Internal Medicine, University of Oklahoma Health Sciences Center
| | - Sindhu Kaitha
- Department of Internal Medicine, University of Oklahoma Health Sciences Center
| | - Sultan Mahmood
- Department of Internal Medicine, University of Oklahoma Health Sciences Center
| | - Abdul Ftesi
- Integris Baptist Hospital, Oklahoma City, Oklahoma, USA
| | - Jordan Stone
- Department of Internal Medicine, University of Oklahoma Health Sciences Center
| | - Michael S Bronze
- Department of Internal Medicine, University of Oklahoma Health Sciences Center
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Zanger P, Kötter I, Kremsner P, Gabrysch S. Tumor necrosis factor alpha antagonist drugs and leishmaniasis in Europe. Clin Microbiol Infect 2012; 18:670-6. [DOI: 10.1111/j.1469-0691.2011.03674.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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14
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[Persistent inflammation of the nasal dorsum in a patient with rheumatoid arthritis treated with infliximab]. Enferm Infecc Microbiol Clin 2011; 30:40-2. [PMID: 21903302 DOI: 10.1016/j.eimc.2011.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Revised: 05/28/2011] [Accepted: 06/29/2011] [Indexed: 11/24/2022]
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