A Case of Visceral Leishmaniasis during Adalimumab Therapy in Patient with Psoriatic Arthritis

Mameli Antonella; Cabiddu Mariano; Guerzoni Filippo; Porru Mariagrazia; Cianchetti Maria Elisabetta

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A Case of Visceral Leishmaniasis during Adalimumab Therapy in Patient with Psoriatic Arthritis

Mameli Antonella^*, Cabiddu Mariano, Guerzoni Filippo, Porru Mariagrazia, Cianchetti Maria Elisabetta , Barcellona Doris and Marongiu Francesco
Department of Internal Medicine and Haemocoagulopathies, University of Cagliari, Italy

^*Corresponding author: Antonella Mameli, Department of Internal Medicine and Haemocoagulopathies, AOU, SS 554, 09042 Monserrato Cagliari, Italy

Published: 16 Jul, 2018
Cite this article as: Antonella M, Mariano C, Filippo G, Mariagrazia P, Elisabetta CM, Doris B, et al. A Case of Visceral Leishmaniasis during Adalimumab Therapy in Patient with Psoriatic Arthritis. Ann Clin Case Rep. 2018; 3: 1535.

Keywords

Psoriatic arthritis; Anti-TNFalpha therapy; Infections and arthritis; Haematopoietic tissue

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We present a case of visceral leishmaniasis infection in patient with psoriatic arthritis. Opportunistic infections have been increasingly recognized with the advent of biological therapy for rheumatic disease. Visceral Leishmaniasis (VL) has been reported in Europe in association with tumour necrosis factor-alpha inhibitors.
Opportunistic infections have been increasingly recognized with the advent of biological therapy for rheumatic disease despite their striking effectiveness. Visceral Leishmaniasis (VL) may represent a rare complication of biological therapy [1-3]. The infection is a zoonosis, with transmission of the parasite by shadflies to rodents and canine. Mediterranean counties are considered to be hypoendemic for VL. We presented a case of 67-year-old man with psoriatic arthritis in treatment with adalimumab and corticosteroids admitted to the ward of our Internal Medicine Unit with persistent fever, night sweats, weight loss and anorexia. Concomitantly he presented a recurrent cutaneous pruritic erythematosus rush of the face and the trunk. Laboratory tests showed pancytopenia and impaired liver function; abdominal ultrasonography and TC scan total body were normal. Over the first week, patient’s fever persisted with spikes up to 40.5°C, and his pancytopenia was deteriorating. We decided to perform a bone marrow aspiration. The smear revealed several intracellular and extracellular Leishmania parasites (Figure 1) and ELISA serology was strongly positive for Leishmania antibodies. Surprisingly, spleen was not enlarged. Adalimumab was withdrawn and treatment with liposomal amphotericin was started. Eight weeks later, leishmaniasis resolved. Our case shows the possibility of atypical presentation of VL. Fever, pancytopenia and alteration of liver function without hepatosplenomegaly are able to mimicking an iatrogenic Lupus Like syndrome. Anti-TNF alfa agents are known to be responsible of autoimmune syndrome [4-5]. VL should be taken into account in the approach to patients presenting fever and pancytopenia while receiving immunosuppressive treatment for rheumatic diseases, especially in endemic areas [2].

Figure 1

Figure 1
Bone marrow smear showing intra and extracellular Leishmania parasites.

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