Clinical Image
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
Clinical Image
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Adalimumab was withdrawn and treatment with liposomal amphotericin was started.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
References
- De Leonardis F, Govoni M, Lo Monaco A, Trotta F. Visceral leishmaniasis and anti-TNF-alpha therapy: Case report and review of the literature. Clin Exp Rheumatol. 2009; 27: 503-6.
- Català A, Roé E, Dalmau J, Pomar V, Muñoz C, Yelamos O, et al. Antitumour necrosis factor-induced visceral and cutaneous leishmaniasis: Case report and review of the literature. Dermatology. 2015; 230: 204-7.
- Guedes-Barbosa LS, Pereira da Costa I, Fernandes V, Henrique da Mota LM, de Menezes I, Aaron Scheinberg M. Leishmaniasis during antitumornecrosis factor therapy: report of 4 cases and review of the literature (additional 28 cases). Semin Arthritis Rheum. 2013; 43: 152-7.
- Kritikos K, Haritatos E, Tsigkos S, Gounari P, Skrapari I, Gounaris T, et al. An atypical presentation of visceral leishmaniasis infection in a patient with rheumatoid arthritis treated with infliximab. J Clin Rheumatol. 2010; 16: 38-9.
- Ramos-Casals M, Brito-Zerón P, Soto MJ, Cuadrado MJ, Khamashta MA. Autoimmune diseases induced by TNF-targeted therapies. Best Pract Res Clin Rheumatol. 2008; 22: 847-61.