Visceral leishmaniasis infection during adalimumab therapy: a case report and literature review

A Patient with Rheumatoid Arthritis under Methotrexate and Etanercept Treatment Presenting with Fever and Pancytopenia: An Unexpected Guest

Leishmania species induce chronic intracellular parasitism, while visceral leishmaniasis can become fatal, if left untreated. Patients with rheumatoid arthritis might feature a genetic predisposition to infection from Leishmania species, besides the status of immunosuppression. Several cases of visceral leishmaniasis in patients with underlying rheumatoid arthritis manifesting with cytopenias with or without organomegaly have been published so far; however, only three cases presenting with pancytopenia without splenomegaly have been described. Herein we describe a case of a 63-year-old woman presenting with fever and pancytopenia without organomegaly on a background of rheumatoid arthritis under methotrexate and etanercept treatment, finally diagnosed with visceral leishmaniasis.

Imported visceral leishmaniasis and immunosuppression in seven Norwegian patients

Background

Visceral leishmaniasis (VL) is a protozoal disease that may be aggravated by immunosuppression. In recent years, a growing number of patients with chronic diseases use biological treatment. When such immunosuppressed patients travel to endemic areas, they are facing the risk of VL. Increased incidence of leishmaniasis is reported in endemic areas like the Mediterranean basin, an area frequently visited by Norwegian tourists. This may lead to an increased number of patients, many presenting to health personnel unfamiliar with the disease, in their home countries.

Methods

We reviewed the files of seven immunosuppressed patients with VL, admitted to Oslo and Haukeland University Hospitals in Norway in the period 2009-2018.

Results

The patients were 41-83 (median 66) years of age; four had rheumatic disease all of whom used methotrexate; one had advanced HIV infection, one had inflammatory bowel disease and one had myelofibrosis. Leishmania infantum was confirmed in five patients by polymerase chain reaction (PCR) and sequencing. In the remaining two patients, a definite Leishmania species could not be identified. All patients had a history of recent recreational travel to Spain. Most patients underwent extensive diagnostic work-up before diagnosed with VL. All received treatment with liposomal amphotericin B and all were cured; albeit two after re-treatment due to relapse.

Conclusions

Visceral leishmaniasis is a potentially life-threatening but usually treatable condition. It is endemic in Southern Europe, including popular tourist destinations such as the Mediterranean basin. It is relatively unknown to most medical practitioners in non-endemic areas and clinical vigilance is required to identify those who are infected.

TNF-Mediated Restriction of Arginase 1 Expression in Myeloid Cells Triggers Type 2 NO Synthase Activity at the Site of Infection

Neutralization or deletion of tumor necrosis factor (TNF) causes loss of control of intracellular pathogens in mice and humans, but the underlying mechanisms are incompletely understood. Here, we found that TNF antagonized alternative activation of macrophages and dendritic cells by IL-4. TNF inhibited IL-4-induced arginase 1 (Arg1) expression by decreasing histone acetylation, without affecting STAT6 phosphorylation and nuclear translocation. In Leishmania major-infected C57BL/6 wild-type mice, type 2 nitric oxide (NO) synthase (NOS2) was detected in inflammatory dendritic cells or macrophages, some of which co-expressed Arg1. In TNF-deficient mice, Arg1 was hyperexpressed, causing an impaired production of NO in situ. A similar phenotype was seen in L. major-infected BALB/c mice. Arg1 deletion in hematopoietic cells protected these mice from an otherwise lethal disease, although their disease-mediating T cell response (Th2, Treg) was maintained. Thus, deletion or TNF-mediated restriction of Arg1 unleashes the production of NO by NOS2, which is critical for pathogen control.

Complications of biologics in inflammatory bowel disease

PURPOSE OF REVIEW

The treatment of inflammatory bowel disease (IBD) in the modern area has improved with more biological agents available. Although the efficacy of these drugs has been demonstrated, concerns about their safety profile have been raised, and new data have emerged in the past year.

RECENT FINDINGS

New data regarding the safety profile of anti-TNF were published over the last year, with a better identification of patients at risk of infection, and specific recommendations for the prevention of infections. There is a mild increase in malignancy in patients receiving anti-TNF, mainly lymphoma and skin cancer, which seems mainly attributable to combination with thiopurines. Specific recommendations for management of pregnancy were published.

SUMMARY

Biological treatments are effective and safe in the treatment of IBD, provided that the recommendations for their use and monitoring are followed.