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Akkuzu G, Ozkara S, Ozgur DS, Karaalioglu B, Yıldırım F, Ayer M, Bes C. Visceral leishmaniasis in a patient with systemic lupus erythematosus: Dilemma in diagnosis and management. Int J Rheum Dis 2022; 26:769-773. [PMID: 36502503 DOI: 10.1111/1756-185x.14510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 11/07/2022] [Accepted: 11/09/2022] [Indexed: 12/14/2022]
Abstract
Patients with systemic lupus erythemasus (SLE) have an increased risk of bacterial, viral, fungal or parasitic infections, especially if they are receiving immunosuppressive therapy. Leishmaniasis is a group of diseases caused by intracellular flagellate protozoan parasites belonging to the genus Leishmania. We present a 48-year-old female patient, diagnosed with SLE many years ago, who presented with high fever and pancytopenia. We thought that the patient's hematologic findings were related to SLE hematologic involvement. However, we investigated other possible causes when there was no response to drugs for the treatment of SLE. A second bone marrow biopsy showed Leishmania amastigotes and the patient was diagnosed with leishmaniasis. The patient was treated with liposomal amphotericin-B (treatment completed at 40 days). She showed rapid clinical improvement and showed no signs of disease after 4 months.
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Affiliation(s)
- Gamze Akkuzu
- Department of Rheumatology Başakşehir Çam and Sakura City Hospital, University of Health Sciences İstanbul Turkey
| | - Selvinaz Ozkara
- Department of Pathology Başakşehir Çam and Sakura City Hospital, University of Health Sciences İstanbul Turkey
| | - Duygu Sevinc Ozgur
- Department of Rheumatology Başakşehir Çam and Sakura City Hospital, University of Health Sciences İstanbul Turkey
| | - Bilgin Karaalioglu
- Department of Rheumatology Başakşehir Çam and Sakura City Hospital, University of Health Sciences İstanbul Turkey
| | - Fatih Yıldırım
- Department of Rheumatology Başakşehir Çam and Sakura City Hospital, University of Health Sciences İstanbul Turkey
| | - Mesut Ayer
- Department of Hematology Başakşehir Çam and Sakura City Hospital, University of Health Sciences İstanbul Turkey
| | - Cemal Bes
- Department of Rheumatology Başakşehir Çam and Sakura City Hospital, University of Health Sciences İstanbul Turkey
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Berger M, Le Falher G, Casanova ML, Borlot F, Alméras M, Jarjour B, Oziol E, Vokaer B. Fais le beau, Tom, pour lécher un sucre ! Rev Med Interne 2019; 40:841-843. [DOI: 10.1016/j.revmed.2019.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 06/23/2019] [Indexed: 11/30/2022]
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Gatto M, Zen M, Iaccarino L, Doria A. New therapeutic strategies in systemic lupus erythematosus management. Nat Rev Rheumatol 2018; 15:30-48. [DOI: 10.1038/s41584-018-0133-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Al-Ghazaly J, Al-Dubai W, Abdullah M, Al-Gharasi L. Hematological Characteristics of Yemeni Adults and Children with Visceral Leishmaniasis. Could Eosinopenia be a Suspicion Index? Mediterr J Hematol Infect Dis 2017; 9:e2017056. [PMID: 28894565 PMCID: PMC5584771 DOI: 10.4084/mjhid.2017.056] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/03/2017] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Delay in the diagnosis of visceral leishmaniasis (VL) particularly in non-endemic areas is associated with higher mortality. In our experience, we found that marked bone marrow eosinopenia was a very frequent accompaniment of VL and might be a useful clue for the diagnosis, which indicates the opportunity for further morphological assessment. The aim of this study was to describe the hematological characteristics including peripheral blood and bone marrow findings of Yemeni adults and children with VL. METHODS We conducted a descriptive analytic study to evaluate systematically peripheral blood and bone marrow findings of Yemeni adults and children with VL. Peripheral blood and bone marrow aspiration of patients with bone marrow aspirate confirmed VL were examined. Forty-seven patients with the main age (±SD) of 17.34±11.37 years (Range: 1-60) were included in the study. Fifty-one non-VL subjects with splenomegaly and pancytopenia or bicytopenia served as control group. RESULTS All patients with VL had anemia, 41 (87%) leukopenia, 42 (89%) neutropenia, 44 (94%) thrombocytopenia, 42 (89%) eosinopenia, 34 (72%) pancytopenia and 13 (28%) had bicytopenia. In bone marrow examination 40 (85%) showed hypercellularity, 44 (94%) eosinopenia, 24 (51%) dyserythropoiesis, 22 (47%) lymphocytosis, 8 (17%) plasmacytosis, 27 (57%) decreased iron stores and 20 (43%) showed decreased sideroblasts. Comparison of VL patients with the control group showed significantly more frequent peripheral blood eosinopenia and lymphopenia and marrow eosinopenia. There was no significant difference between adults and children in any of the hematological features. CONCLUSION Anemia, leukopenia, neutropenia, thrombocytopenia, eosinopenia, pancytopenia and marked bone marrow eosinopenia were the most common findings. The finding of marked bone marrow eosinopenia is a significant clue for the diagnosis of visceral leishmaniasis in patients who present with splenomegaly associated with cytopenias. This finding is particularly valuable in non-endemic areas.
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Affiliation(s)
- Jameel Al-Ghazaly
- Department of Medicine, Faculty of Medicine and Health Sciences, Sana’a University, Sana’a, Yemen
- Department of Medicine, Hematology Unit, Al-Jomhori Teaching Hospital, Sana’a, Yemen
| | - Waled Al-Dubai
- Department of Biochemistry and cytogenetics, Faculty of Medicine and Health Sciences, Sana’a University, Sana’a, Yemen
| | | | - Leila Al-Gharasi
- Department of Medicine, Hematology Unit, Al-Jomhori Teaching Hospital, Sana’a, Yemen
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Santana IU, Dias B, Nunes EAS, Rocha FACD, Silva FS, Santiago MB. Visceral leishmaniasis mimicking systemic lupus erythematosus: Case series and a systematic literature review. Semin Arthritis Rheum 2014; 44:658-65. [PMID: 25704907 DOI: 10.1016/j.semarthrit.2014.12.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 12/10/2014] [Accepted: 12/19/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Systemic lupus erythematosus (SLE) is an autoimmune disease that may present manifestations that resemble other diseases. Visceral leishmaniasis (VL) is a parasitic infection whose hallmarks may mimic SLE symptoms. Here, we report a case series and evaluate the published, scientific evidence of the relationship between SLE and VL infection. METHODS To assess original studies reporting cases of VL-infected patients presenting manifestations that are capable of leading to inappropriate suspicions of SLE or mimicking an SLE flare, we performed an extensive search in several scientific databases (MEDLINE, LILACS, SciELO, and Scopus). Two authors independently screened all citations and abstracts identified by the search strategy to identify eligible studies. Secondary references were additionally obtained from the selected articles. RESULTS The literature search identified 53 eligible studies, but only 17 articles met our criteria. Among these, 10 lupus patients with VL mimicking an SLE flare and 18 cases of VL leading to unappropriated suspicions of SLE were described. The most common manifestations in patients infected with VL were intermittent fever, pancytopenia, visceromegaly, and increased serum level of acute phase reactants. The most frequent autoantibodies were antinuclear antibodies, rheumatoid factor, and direct Coombs' test. CONCLUSION In endemic areas for VL, the diagnosis of SLE or its exacerbation may be a clinical dilemma. Hepatosplenomegaly or isolated splenomegaly was identified in the majority of the reported cases where VL occurred, leading to unappropriated suspicions of SLE or mimicking an SLE flare. Furthermore, the lack of response to steroids, the normal levels of complement proteins C3 and C4, and the increased level of transaminases suggest a possible infectious origin.
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Affiliation(s)
- Iuri Usêda Santana
- Serviço de Clínica Médica do Hospital Geral Roberto Santos, Salvador, Brazil
| | - Blenda Dias
- Serviços Especializados em Reumatologia (SER) da Bahia, Rua Conde Filho, 117, Graça, Salvador, Bahia CEP 40150-150, Brazil
| | - Eduardo Araújo Santana Nunes
- Serviços Especializados em Reumatologia (SER) da Bahia, Rua Conde Filho, 117, Graça, Salvador, Bahia CEP 40150-150, Brazil
| | | | | | - Mittermayer Barreto Santiago
- Serviços Especializados em Reumatologia (SER) da Bahia, Rua Conde Filho, 117, Graça, Salvador, Bahia CEP 40150-150, Brazil.
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Leishmaniasis and autoimmune diseases in pediatric age. Cell Immunol 2014; 292:9-13. [DOI: 10.1016/j.cellimm.2014.08.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 07/23/2014] [Accepted: 08/18/2014] [Indexed: 12/27/2022]
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Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by multisystem organ involvement, heterogeneity of clinical features, and variety in degree of severity. The differential diagnosis is a crucial aspect in SLE as many other autoimmune diseases portray clinical similarities and autoantibody positivity. Lupus mimickers refer to a group of conditions that exhibit both clinical features and laboratory characteristics, including autoantibody profiles that resemble those present in patients with SLE, and prompt a diagnostic challenge in everyday clinical practice. Thus, lupus mimickers may present as a lupus-like condition (i.e., 2 or 3 criteria) or as one meeting the classification criteria for SLE. Herein we review and classify the current literature on lupus mimickers based on diverse etiologies which include infections, malign and benign neoplasms, medications, and vaccine-related reactions.
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Affiliation(s)
- Omar-Javier Calixto
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia; Mederi, Hospital Universitario Mayor, Bogotá, Colombia
| | - Juan-Sebastian Franco
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia; Mederi, Hospital Universitario Mayor, Bogotá, Colombia
| | - Juan-Manuel Anaya
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia; Mederi, Hospital Universitario Mayor, Bogotá, Colombia.
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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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Autoimmune manifestations in patients with visceral leishmaniasis. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2013; 46:302-5. [DOI: 10.1016/j.jmii.2012.01.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2011] [Revised: 12/27/2011] [Accepted: 01/09/2012] [Indexed: 12/17/2022]
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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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Tunccan OG, Tufan A, Telli G, Akyürek N, Pamukçuoğlu M, Yılmaz G, Hızel K. Visceral leishmaniasis mimicking autoimmune hepatitis, primary biliary cirrhosis, and systemic lupus erythematosus overlap. THE KOREAN JOURNAL OF PARASITOLOGY 2012; 50:133-6. [PMID: 22711924 PMCID: PMC3375451 DOI: 10.3347/kjp.2012.50.2.133] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Revised: 03/03/2012] [Accepted: 03/03/2012] [Indexed: 11/23/2022]
Abstract
Visceral leishmaniasis (VL) is a life-threatening infection caused by Leishmania species. In addition to typical clinical findings as fever, hepatosplenomegaly, and cachexia, VL is associated with autoimmune phenomena. To date, VL mimicking or exacerbating various autoimmune diseases have been described, including systemic lupus erythematosus (SLE), rheumatoid arthritis, and autoimmune hepatitis (AIH). Herein, we presented a patient with VL who had overlapping clinical features with SLE, AIH, as well as antimitochondrial antibody (AMA-M2) positive primary biliary cirrhosis.
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Affiliation(s)
- Ozlem Guzel Tunccan
- Department of Clinical Microbiology and Infectious Diseases, Gazi University Hospital Besevler, 06500 Ankara, Turkey.
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