Visceral leishmaniasis complicating a connective tissue disease: three case reports from Italy

Effect of immunosuppressants on the parasite load developed in, and immune response to, visceral leishmaniasis: A comparative study in a mouse model

The increasing use of immunosuppressants in areas where visceral leishmaniasis (VL) is endemic has increased the number of people susceptible to developing more severe forms of the disease. Few studies have examined the quality of the immune response in immunosuppressed patients or experimental animals with VL. The present work characterises the parasite load developed in, and immune response to, Leishmania infantum-induced VL in C57BL/6 mice that, prior to and during infection, received immunosuppressant treatment with methylprednisolone (MPDN), anti-tumour necrosis factor (anti-TNF) antibodies, or methotrexate (MTX). The latter two treatments induced a significant reduction in the number of CD4+ T lymphocytes over the infection period. The anti-TNF treatment was also associated with a higher parasite load in the liver and a lower parasite load in the spleen. This, plus a possibly treatment-induced reduction in the number of cytokine-producing Th1 cells in the spleen, indicates the development of more severe VL. Interestingly, the MPDN and (especially) MTX treatments provoked a greater presence of soluble Leishmania antigen-specific multi-cytokine-producing T cells in the spleen and a lower liver parasite load than in control animals. These results highlight the need to better understand how immunosuppressant treatments might influence the severity of VL in human patients.

Visceral leishmaniasis mimicking systemic lupus erythematosus: Case series and a systematic literature review

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.

Imported case of visceral leishmaniasis presenting as pancytopenia in a Norwegian patient treated with methotrexate and etanercept for psoriasis arthritis

We report a case of visceral leishmaniasis in a patient from northern Norway with psoriatic arthritis treated with a combination of etanercept and methotrexate. The patient resided extensively in southern Spain, a zone endemic for leishmania.

Prolonged fever, hepatosplenomegaly, and pancytopenia in a 46-year-old woman

Liran Levy and colleagues discuss the differential diagnosis, investigation, and management of a 46-year-old woman with fever, weakness, night sweats, and weight loss.

Atypical cutaneous leishmaniasis in two patients receiving low-dose methotrexate

Cutaneous leishmaniasis is a protozoan disease that has high morbidity. There have been increasing reports of leishmaniasis in patients with an underlying immunosuppressed state. We present two cases of cutaneous leishmaniasis caused by Old World species in patients on methotrexate therapy. We postulate that the T-cell-mediated response to leishmaniasis infection could be modulated by methotrexate and may render an immunosuppressed individual more susceptible to developing clinical disease.

Leishmania infantum leishmaniasis in corticosteroid--treated patients

Background

The number of leishmaniasis cases associated with immunosuppression has increased regularly over the past 20 years. Immunosuppression related to HIV infection, immunosuppressive treatment, organ transplantation, and neoplastic diseases increases the risk for Leishmania-infected people to develop visceral illness.

Case presentation

Three cases of Leishmania infantum leishmaniasis in corticosteroid (CS)-treated patients are reported: an isolated lingual leishmaniasis in a farmer treated with CS for asthma, a severe visceral leishmaniasis associated with cutaneous lesions in a woman with myasthenia gravis, and a visceral involvement after cutaneous leishmaniasis in a man receiving CS.

Conclusion

Physicians should recognise CS-treated patients as a population likely to be immunesuppressed. In immunodeficiency conditions, unusual forms of leishmaniasis can develop and foster the risk of a diagnostic delay and of poor response to therapy.

Comparison of the efficacy and pharmacology of formulations of amphotericin B used in treatment of leishmaniasis

PURPOSE OF REVIEW

Several lipid-based formulations of the antifungal and antiparasitic drug amphotericin B are now available on the market. The purpose of this review is to assess their efficacy against leishmaniasis in both experimental and clinical settings, and to point out new developments in the formulation of this antibiotic.

RECENT FINDINGS

The development of resistance to pentavalent antimony compounds has shifted the emphasis to amphotericin B for the treatment of visceral leishmaniasis in India. Lipid formulations show good efficacy but are expensive. The treatment period with lipid formulations is shorter, however, which reduces hospitalization costs. As a result, in developed countries where these costs are an important proportion of the treatment, lipid formulations are preferred, whereas they remain largely inaccessible in developing countries. Lipid-associated amphotericin B has been found to be effective for secondary prophylaxis in HIV-positive patients, in studies carried out in European countries bordering the Mediterranean.

SUMMARY

The reduced toxicity of lipid-based formulations of amphotericin B is no longer in doubt. In India, their efficacy against visceral leishmaniasis and shorter treatment periods compared with the conventional formulation with deoxycholate has to be counter-balanced against the very high cost. By contrast, in developed countries around the Mediterranean, where leishmaniasis occurs mainly in immunocompromised individuals, lipid formulations have become the treatment of choice for visceral disease. The efficacy against cutaneous lesions is variable, however, and in some reports oral miltefosine was active after failure of treatment with amphotericin B.