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Palacios-Diaz RD, Sahuquillo-Torralba A, Rocamora-Durán V, Unamuno-Bustos BD, Salavert-Lleti M, Santos-Alarcón S, Quintero A, Garcías-Ladaria J, Vila-Payeras A, Martínez-Doménech A, Mateu-Puchades A, Nadal-Lladó C, Botella-Estrada R. Klinisch-pathologische Eigenschaften kutaner und mukokutaner Leishmaniose bei mit TNF-α-Inhibitoren behandelten Patienten. J Dtsch Dermatol Ges 2023; 21:473-481. [PMID: 37183744 DOI: 10.1111/ddg.15007_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 01/03/2023] [Indexed: 05/16/2023]
Affiliation(s)
| | | | | | | | - Miguel Salavert-Lleti
- Infectious Diseases Department, Hospital Universitario y Politécnico La Fe, Valencia, Spanien
| | | | - Adriana Quintero
- Pathology Department, Hospital de Manacor, Illes Baleares, Spanien
| | - Joan Garcías-Ladaria
- Dermatology Department, Hospital Universitario Son Espases, Illes Baleares, Spanien
| | - Aina Vila-Payeras
- Dermatology Department, Hospital Universitario Son Llàtzer, Palma de Mallorca, Illes Baleares, Spanien
| | | | | | - Cristina Nadal-Lladó
- Dermatology Department, Hospital Universitario Son Llàtzer, Palma de Mallorca, Illes Baleares, Spanien
| | - Rafael Botella-Estrada
- Dermatology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spanien
- Department of Medicine, Universitat de València, Valencia, Spanien
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Patoulias D, Papachristou S, Gouridou E, Stamou D, Chissan S, Bakatselos S. A Patient with Rheumatoid Arthritis under Methotrexate and Etanercept Treatment Presenting with Fever and Pancytopenia: An Unexpected Guest. Mediterr J Rheumatol 2021; 32:160-163. [PMID: 34447913 PMCID: PMC8369276 DOI: 10.31138/mjr.32.2.160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 01/26/2021] [Accepted: 02/15/2021] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Dimitrios Patoulias
- First Department of Internal Medicine, General Hospital of Thessaloniki "Hippokration", Thessaloniki, Greece
| | - Savvas Papachristou
- First Department of Internal Medicine, General Hospital of Thessaloniki "Hippokration", Thessaloniki, Greece
| | - Evgenia Gouridou
- First Department of Internal Medicine, General Hospital of Thessaloniki "Hippokration", Thessaloniki, Greece
| | - Dafni Stamou
- First Department of Internal Medicine, General Hospital of Thessaloniki "Hippokration", Thessaloniki, Greece
| | - Sofia Chissan
- Haematology Section, Second Propaedeutic Department of Internal Medicine, General Hospital of Thessaloniki "Hippokration", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Spyridon Bakatselos
- First Department of Internal Medicine, General Hospital of Thessaloniki "Hippokration", Thessaloniki, Greece
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Curtin JM, Aronson NE. Leishmaniasis in the United States: Emerging Issues in a Region of Low Endemicity. Microorganisms 2021; 9:578. [PMID: 33799892 PMCID: PMC7998217 DOI: 10.3390/microorganisms9030578] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/08/2021] [Accepted: 03/10/2021] [Indexed: 12/12/2022] Open
Abstract
Leishmaniasis, a chronic and persistent intracellular protozoal infection caused by many different species within the genus Leishmania, is an unfamiliar disease to most North American providers. Clinical presentations may include asymptomatic and symptomatic visceral leishmaniasis (so-called Kala-azar), as well as cutaneous or mucosal disease. Although cutaneous leishmaniasis (caused by Leishmania mexicana in the United States) is endemic in some southwest states, other causes for concern include reactivation of imported visceral leishmaniasis remotely in time from the initial infection, and the possible long-term complications of chronic inflammation from asymptomatic infection. Climate change, the identification of competent vectors and reservoirs, a highly mobile populace, significant population groups with proven exposure history, HIV, and widespread use of immunosuppressive medications and organ transplant all create the potential for increased frequency of leishmaniasis in the U.S. Together, these factors could contribute to leishmaniasis emerging as a health threat in the U.S., including the possibility of sustained autochthonous spread of newly introduced visceral disease. We summarize recent data examining the epidemiology and major risk factors for acquisition of cutaneous and visceral leishmaniasis, with a special focus on implications for the United States, as well as discuss key emerging issues affecting the management of visceral leishmaniasis.
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Affiliation(s)
- John M. Curtin
- Infectious Diseases Service, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
- Infectious Diseases Division, Uniformed Services University, Bethesda, MD 20814, USA;
| | - Naomi E. Aronson
- Infectious Diseases Division, Uniformed Services University, Bethesda, MD 20814, USA;
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Bosch-Nicolau P, Ubals M, Salvador F, Sánchez-Montalvá A, Aparicio G, Erra A, Martinez de Salazar P, Sulleiro E, Molina I. Leishmaniasis and tumor necrosis factor alpha antagonists in the Mediterranean basin. A switch in clinical expression. PLoS Negl Trop Dis 2019; 13:e0007708. [PMID: 31469834 PMCID: PMC6742442 DOI: 10.1371/journal.pntd.0007708] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 09/12/2019] [Accepted: 08/15/2019] [Indexed: 02/02/2023] Open
Abstract
Background Tumor necrosis factor alpha (TNF-α) blockers are recognized as a risk factor for reactivation of granulomatous infections. Leishmaniasis has been associated with the use of these drugs, although few cases have been reported. Methodology We performed a retrospective observational study including patients with confirmed leishmaniasis acquired in the Mediterranean basin that were under TNF-α blockers therapy at the moment of the diagnosis. Patients diagnosed in our hospital from 2008 to 2018 were included. Moreover, a systematic review of the literature was performed and cases fulfilling the inclusion criteria were also included. Principal findings Forty-nine patients were analyzed including nine cases from our series. Twenty-seven (55.1%) cases were male and median age was 55 years. Twenty-five (51%) patients were under infliximab treatment, 20 (40.8%) were receiving adalimumab, 2 (4.1%) etanercept, one (2%) golimumab and one (2%) a non-specified TNF-α blocker. Regarding clinical presentation, 28 (57.1%) presented as cutaneous leishmaniasis (CL), 16 (32.6%) as visceral leishmaniasis (VL) and 5 (10.2%) as mucocutaneous leishmaniasis (MCL). All VL and MCL patients were treated with systemic therapies. Among CL patients, 13 (46.4%) were treated with a systemic drug (11 received L-AmB, one intramuscular antimonials and one miltefosine) while 14 (50%) patients were given local treatment (13 received intralesional pentavalent antimonials, and one excisional surgery). TNF-α blockers were interrupted in 32 patients (65.3%). After treatment 5 patients (10.2%) relapsed. Four patients with a CL (3 initially treated with local therapy maintaining TNF-α blockers and one treated with miltefosine) and one patient with VL treated with L-AmB maintaining TNF-α blockers. Conclusions This data supports the assumption that the blockage of TNF-α modifies clinical expression of leishmaniasis in endemic population modulating the expression of the disease leading to atypical presentations. According to the cases reported, the best treatment strategy would be a systemic drug and the discontinuation of the TNF-α blockers therapy until clinical resolution. Tumor necrosis factor alpha (TNF-α) blockers are widely used in numerous inflammatory diseases such rheumatoid arthritis, psoriasis or inflammatory bowel diseases. They have been recognized as a risk factor for reactivation of granulomatous infections. Although few cases have been reported, Leishmaniasis has been associated with the use of these drugs. Leishmania infantum is the main causative agent of leishmaniasis in Southern Europe and is prone to produce the visceral form. However, TNF-α has been implicated in the initial events of the infection mediating the disease expression. In our series, we have observed a surprisingly high proportion of cutaneous form (32.6%) and muco-cutaneous form (10.2%). Clinical outcome observed in this series is also unusual. Four cases (14.3%) with cutaneous leishmaniasis who received local therapy relapsed. Among patients with visceral leishmaniasis, one patient who maintained TNF-α blockers therapy relapsed despite etiological treatment. This data supports the assumption that the blockage of TNF-α modifies clinical expression of leishmaniasis leading to atypical presentations. According to the cases reported we proposed as best treatment strategy a systemic drug and the discontinuation of the TNF-α blockers therapy until clinical resolution.
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Affiliation(s)
- Pau Bosch-Nicolau
- Department of Infectious Diseases, Hospital Universitari Vall d’Hebron, PROSICS Barcelona, Universitat Autònoma de Barcelona, Spain
| | - Maria Ubals
- Department of Dermatology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Spain
| | - Fernando Salvador
- Department of Infectious Diseases, Hospital Universitari Vall d’Hebron, PROSICS Barcelona, Universitat Autònoma de Barcelona, Spain
| | - Adrián Sánchez-Montalvá
- Department of Infectious Diseases, Hospital Universitari Vall d’Hebron, PROSICS Barcelona, Universitat Autònoma de Barcelona, Spain
| | - Gloria Aparicio
- Department of Dermatology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Spain
| | - Alba Erra
- Department of Rheumatology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Spain
| | - Pablo Martinez de Salazar
- Department of Clinical Microbiology, Hospital Universitari Vall d’Hebron, PROSICS Barcelona, Universitat Autònoma de Barcelona, Spain
| | - Elena Sulleiro
- Department of Clinical Microbiology, Hospital Universitari Vall d’Hebron, PROSICS Barcelona, Universitat Autònoma de Barcelona, Spain
| | - Israel Molina
- Department of Infectious Diseases, Hospital Universitari Vall d’Hebron, PROSICS Barcelona, Universitat Autònoma de Barcelona, Spain
- * E-mail:
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Immunotherapy in clinical canine leishmaniosis: a comparative update. Res Vet Sci 2019; 125:218-226. [PMID: 31280121 DOI: 10.1016/j.rvsc.2019.06.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 05/22/2019] [Accepted: 06/18/2019] [Indexed: 12/13/2022]
Abstract
Leishmaniosis due to Leishmania infantum is a complex infection that can affect both humans and dogs, and present a wide range of clinical signs and clinicopathological abnormalities. The conventional treatment of this disease is challenging due to the fact that complete parasitological cure commonly does not occur. Furthermore, treatment of the disease with the conventionally used drugs has several shortcomings. These include the need for long-term treatment, side effects and the formation of drug resistance. Moreover, it is important to highlight that the host immune responses play a crucial role in the outcome of this infection. For this reason, the use of immunotherapy in clinical leishmaniosis to improve the result of treatment with the conventional anti-leishmanial drugs by enhancing the immune response is imperative. The aim of this review is to provide a comparative overview of the wide range of immunotherapeutical approaches and strategies for the treatment of L. infantum infection in animals focusing on dogs.
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6
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Dayakar A, Chandrasekaran S, Kuchipudi SV, Kalangi SK. Cytokines: Key Determinants of Resistance or Disease Progression in Visceral Leishmaniasis: Opportunities for Novel Diagnostics and Immunotherapy. Front Immunol 2019; 10:670. [PMID: 31024534 PMCID: PMC6459942 DOI: 10.3389/fimmu.2019.00670] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 03/12/2019] [Indexed: 12/31/2022] Open
Abstract
Leishmaniasis is a parasitic disease of humans, highly prevalent in parts of the tropics, subtropics, and southern Europe. The disease mainly occurs in three different clinical forms namely cutaneous, mucocutaneous, and visceral leishmaniasis (VL). The VL affects several internal organs and is the deadliest form of the disease. Epidemiology and clinical manifestations of VL are variable based on the vector, parasite (e.g., species, strains, and antigen diversity), host (e.g., genetic background, nutrition, diversity in antigen presentation and immunity) and the environment (e.g., temperature, humidity, and hygiene). Chemotherapy of VL is limited to a few drugs which is expensive and associated with profound toxicity, and could become ineffective due to the parasites developing resistance. Till date, there are no licensed vaccines for humans against leishmaniasis. Recently, immunotherapy has become an attractive strategy as it is cost-effective, causes limited side-effects and do not suffer from the downside of pathogens developing resistance. Among various immunotherapeutic approaches, cytokines (produced by helper T-lymphocytes) based immunotherapy has received great attention especially for drug refractive cases of human VL. Therefore, a comprehensive knowledge on the molecular interactions of immune cells or components and on cytokines interplay in the host defense or pathogenesis is important to determine appropriate immunotherapies for leishmaniasis. Here, we summarized the current understanding of a wide-spectrum of cytokines and their interaction with immune cells that determine the clinical outcome of leishmaniasis. We have also highlighted opportunities for the development of novel diagnostics and intervention therapies for VL.
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Affiliation(s)
| | | | - Suresh V Kuchipudi
- Animal Diagnostic Laboratory, Department of Veterinary and Biomedical Sciences, The Pennsylvania State University, University Park, PA, United States
| | - Suresh K Kalangi
- Department of Biosciences, School of Sciences, Indrashil University, Mehsana, India
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Ramos JM, León R, Merino E, Montero M, Aljibe A, Blanes M, Reus S, Boix V, Salavert M, Portilla J. Is Visceral Leishmaniasis Different in Immunocompromised Patients Without Human Immunodeficiency Virus? A Comparative, Multicenter Retrospective Cohort Analysis. Am J Trop Med Hyg 2017; 97:1127-1133. [PMID: 29016284 DOI: 10.4269/ajtmh.16-0940] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Although visceral leishmaniasis (VL) can affect immunocompromised patients, data from the human immunodeficiency virus (HIV) infection context are limited, and the characteristics of VL in other immunosuppression scenarios are not well defined. A retrospective review of all cases of VL in immunocompromised patients from January 1997 to December 2014 in two Spanish hospitals on the Mediterranean coast was performed. We included 18 transplant recipients (kidney: 7, liver: 4, lung: 3, heart: 2, and blood marrow: 2), 12 patients with other causes of immunosuppression (myasthenia gravis: 3 and rheumatoid arthritis: 2), and 73 VL HIV-positive patients. Fever was more common in transplant patients (94.4%) and patients with other types of immunosuppression (100%) than in HIV-positive individuals (73.3%). Hepatomegaly was less common in transplant recipients (27.8%) and patients with other types of immunosuppression (41.7%) compared with HIV-positive patients (69.9%) (P = 0.01; P = 0.001, respectively). Patients with other types of immunosuppression had a median leukocyte count of 1.5 × 109/L, significantly lower than HIV-positive patients (2.5 × 109/L) (P = 0.04). Serology was more commonly positive in nontransplant immunosuppressed individuals (75%) and transplant recipients (78.6%) than in HIV-patients (13.8%) (P < 0.001). Antimonial therapy was rarely used in transplant recipients (1.9%) and never in patients with other immunosuppressive conditions, whereas 34.2% of HIV-positive patients received it (P = 0.05 and P = 0.01, respectively). Mortality was 16.7% in both transplant recipients and patients with other immunosuppressive conditions and 15.1% in HIV-positive patients. The features of VL may be different in immunosuppressed patients, with more fever and less hepatomegaly and leukopenia than in HIV-infected patients.
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Affiliation(s)
- José M Ramos
- Department of Internal Medicine, Hospital General Universitario de Alicante, Alicante, Spain.,Department of Clinical Medicine, Universidad Miguel Hernández de Elche, Campus of San Juan de Alicante, Alicante, Spain
| | - Rafael León
- Department of Clinical Medicine, Universidad Miguel Hernández de Elche, Campus of San Juan de Alicante, Alicante, Spain.,Department of Internal Medicine, Hospital General Universitario de Alicante, Alicante, Spain
| | - Esperanza Merino
- Unit of Infectious Diseases, Department of Internal Medicine, Hospital General Universitario de Alicante. Alicante, Spain.,Department of Clinical Medicine, Universidad Miguel Hernández de Elche, Campus of San Juan de Alicante, Alicante, Spain
| | - Marta Montero
- Unit of Infectious Diseases and Department of Internal Medicine, Hospital Universitario-Politecnico La Fe, Valencia, Spain
| | - Asunción Aljibe
- Unit of Infectious Diseases and Department of Internal Medicine, Hospital Universitario-Politecnico La Fe, Valencia, Spain
| | - Marino Blanes
- Unit of Infectious Diseases and Department of Internal Medicine, Hospital Universitario-Politecnico La Fe, Valencia, Spain
| | - Sergio Reus
- Unit of Infectious Diseases, Department of Internal Medicine, Hospital General Universitario de Alicante. Alicante, Spain.,Department of Clinical Medicine, Universidad Miguel Hernández de Elche, Campus of San Juan de Alicante, Alicante, Spain
| | - Vicente Boix
- Unit of Infectious Diseases, Department of Internal Medicine, Hospital General Universitario de Alicante. Alicante, Spain.,Department of Clinical Medicine, Universidad Miguel Hernández de Elche, Campus of San Juan de Alicante, Alicante, Spain
| | - Miguel Salavert
- Department of Clinical Medicine, Universidad Miguel Hernández de Elche, Campus of San Juan de Alicante, Alicante, Spain
| | - Joaquín Portilla
- Unit of Infectious Diseases, Department of Internal Medicine, Hospital General Universitario de Alicante. Alicante, Spain.,Department of Clinical Medicine, Universidad Miguel Hernández de Elche, Campus of San Juan de Alicante, Alicante, Spain.,Department of Internal Medicine, Hospital General Universitario de Alicante, Alicante, Spain
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8
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Downey C. Serious infection during etanercept, infliximab and adalimumab therapy for rheumatoid arthritis: A literature review. Int J Rheum Dis 2015. [DOI: 10.1111/1756-185x.12659] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Colum Downey
- Graduate Entry Medical School; University of Limerick; Limerick Ireland
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9
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Català A, Roé E, Dalmau J, Pomar V, Muñoz C, Yelamos O, Puig L. Anti-Tumour Necrosis Factor-Induced Visceral and Cutaneous Leishmaniasis: Case Report and Review of the Literature. Dermatology 2015; 230:204-7. [DOI: 10.1159/000370238] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 12/01/2014] [Indexed: 11/19/2022] Open
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10
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Tung Chen Y, Perales C, Lacruz J, Senent L, Salavert M. Visceral leishmaniasis infection during adalimumab therapy: a case report and literature review. Int J Rheum Dis 2014; 17:822-4. [DOI: 10.1111/1756-185x.12427] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Yale Tung Chen
- Department of Internal Medicine; University and Polytechnic Hospital of la Fe; Valencia Spain
| | - Carolina Perales
- Department of Allergy; University and Polytechnic Hospital of la Fe; Valencia Spain
| | - Jose Lacruz
- Department of Infectious Diseases; University and Polytechnic Hospital of la Fe; Valencia Spain
| | - Leonor Senent
- Department of Hematology; University and Polytechnic Hospital of la Fe; Valencia Spain
| | - Miguel Salavert
- Department of Infectious Diseases; University and Polytechnic Hospital of la Fe; Valencia Spain
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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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Five-year retrospective Italian multicenter study of visceral leishmaniasis treatment. Antimicrob Agents Chemother 2013; 58:414-8. [PMID: 24189252 DOI: 10.1128/aac.00840-13] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The treatment of visceral leishmaniasis (VL) is poorly standardized in Italy in spite of the existing evidence. All consecutive patients with VL admitted at 15 Italian centers as inpatients or outpatients between January 2004 and December 2008 were retrospectively considered; outcome data at 1 year after treatment were obtained for all but 1 patient. Demographic characteristics, underlying diseases, diagnostic procedures, treatment regimens and outcomes, as well as side effects were recorded. A confirmed diagnosis of VL was reported for 166 patients: 120 (72.3%) immunocompetent, 21 (12.6%) patients with immune deficiencies other than HIV infection, and 25 (15.1%) coinfected with HIV. Liposomal amphotericin B (L-AmB) was the drug almost universally used for treatment, administered to 153 (92.2%) patients. Thirty-seven different regimens, including L-AmB were used. The mean doses were 29.4 ± 7.9 mg/kg in immunocompetent patients, 32.9 ± 8.6 mg/kg in patients with non-HIV-related immunodeficiencies, and 40.8 ± 6.7 mg/kg in HIV-infected patients (P < 0.001). The mean numbers of infusion days were 7.8 ± 3.1 in immunocompetent patients, 9.6 ± 3.9 in non-HIV-immunodeficient patients, and 12.0 ± 3.4 in HIV-infected patients (P < 0.001). Mild and reversible adverse events were observed in 12.2% of cases. Responsive patients were 154 (93.3%). Successes were 98.4% among immunocompetent patients, 90.5% among non-HIV-immunodeficient patients, and 72.0% among HIV-infected patients. Among predictors of primary response to treatment, HIV infection and age held independent associations in the final multivariate models, whereas the doses and duration of L-AmB treatment were not significantly associated. Longer treatments and higher doses of L-AmB were not able to significantly modify treatment outcomes either in the immunocompetent or in the immunocompromised population.
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13
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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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14
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Zanger P, Kötter I, Kremsner P, Gabrysch S. Tumor necrosis factor alpha antagonist drugs and leishmaniasis in Europe. Clin Microbiol Infect 2012; 18:670-6. [DOI: 10.1111/j.1469-0691.2011.03674.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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15
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Garcia-Gonzalez E, Guidelli GM, Bardelli M, Maggio R. Mucocutaneous leishmaniasis in a patient treated with anti-TNF- therapy. Rheumatology (Oxford) 2012; 51:1517-8. [DOI: 10.1093/rheumatology/kes030] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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17
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[Persistent inflammation of the nasal dorsum in a patient with rheumatoid arthritis treated with infliximab]. Enferm Infecc Microbiol Clin 2011; 30:40-2. [PMID: 21903302 DOI: 10.1016/j.eimc.2011.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Revised: 05/28/2011] [Accepted: 06/29/2011] [Indexed: 11/24/2022]
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18
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Khan A, Coakley G, Cosgrove C, Lockwood D. Let off the leash: kala-azar following the use of tumour necrosis factor antibodies. BMJ Case Rep 2010; 2010:2010/oct12_2/bcr0420102878. [PMID: 22789834 DOI: 10.1136/bcr.04.2010.2878] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 74-year-old woman with a history of psoriatic arthritis was referred to the Hospital for Tropical Diseases following investigation of a skin lesion that had failed to heal after a visit to Malta 2 years previously. Skin biopsy had revealed invasion of Leishmania amastigotes. She reported a recent history of weight loss, dry cough and dyspnoea, and was investigated for pancytopenia and hepatosplenomegaly. Bone marrow biopsy confirmed the diagnosis of visceral leishmaniasis and she responded well to treatment with intravenous liposomal amphotericin B. Recent rheumatological treatment with adalimumab, a monoclonal antibody to tumour necrosis factor α, was thought to be the factor responsible for causing the cutaneous lesion to become disseminated. This case highlights an unexpected adverse effect of novel immunosuppressants. As the use of biologics becomes widespread, there is an increasing need for clinical surveillance.
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Affiliation(s)
- Anjum Khan
- Department of Haematology, Guy's and St Thomas' Hospital NHS Trust, London, UK.
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Tordini G, Giaccherini R, Sammarro G, Braito A, Zanelli G. Human leishmaniasis in Tuscany: a changing pattern of visceral disease? ANNALS OF TROPICAL MEDICINE AND PARASITOLOGY 2010; 104:171-4. [PMID: 20406584 DOI: 10.1179/136485910x12647085215499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- G Tordini
- Department of Molecular Biology, Siena University, Policlinico Santa Maria alle Scotte, Siena, Italy.
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20
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Moltó A, Mateo L, Lloveras N, Olivé A, Minguez S. Visceral leishmaniasis and macrophagic activation syndrome in a patient with rheumatoid arthritis under treatment with adalimumab. Joint Bone Spine 2010; 77:271-3. [DOI: 10.1016/j.jbspin.2010.01.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Accepted: 01/13/2010] [Indexed: 11/26/2022]
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21
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An atypical presentation of visceral leishmaniasis infection in a patient with rheumatoid arthritis treated with infliximab. J Clin Rheumatol 2010; 16:38-9. [PMID: 20051756 DOI: 10.1097/rhu.0b013e3181c8aa33] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Tumor necrosis factor alpha (TNF-alpha) is a cytokine, implicated in the pathogenesis of many inflammatory diseases, as well as in the immune-mediated response to infection, especially against intracellular pathogens. TNF-alpha antagonists have represented a revolution in the management of connective tissue diseases, such as rheumatoid arthritis. However, the use of these agents has been implicated with the emergence of a growing number of opportunistic infections. Here we report the case of a visceral Leishmaniasis in a 77-year-old woman who had been previously treated for rheumatoid arthritis with infliximab. The atypical presentation of this patient, previously treated with an anti-TNF-alpha biologic agent, where no splenomegaly or hepatomegaly was identified, is emphasized.
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22
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Marie I, Guglielmino E. [Non tuberculous anti-TNF associated opportunistic infections]. Rev Med Interne 2010; 31:353-60. [PMID: 20381217 DOI: 10.1016/j.revmed.2009.04.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2009] [Revised: 04/27/2009] [Accepted: 04/29/2009] [Indexed: 02/06/2023]
Abstract
Anti-TNFalpha agents have revolutionized the treatment of patients with rheumatoid arthritis, spondylarthropathies and Crohn's disease. However, their use is associated with an increased risk of infections. Pyogenic infections (involving the lungs, skin and urinary tract) and tuberculosis are the more commonly observed infectious complications in patients receiving anti-TNFalpha agents. However, opportunistic infections have been increasingly reported in anti-TNFalpha-treated patients, and include non tuberculous mycobacteria, fungi (Pneumocystis jiroveci, Candida sp, Aspergillus, Cryptococcus, Histoplasma), opportunistic bacterial (Nocardia), parasitic (Leishmania) and viral (e.g. Cytomegalovirus, human herpes virus 8 [HHV 8]) infections. These infectious complications usually occur within the first months of therapy and are important causes of morbidity and mortality in anti-TNFalpha-treated patients. It is recommended to rule out infections, especially latent or active tuberculosis, before the initiation of anti-TNFalpha therapy. However, it is necessary to follow-up closely these patients to detect the possible occurrence of opportunistic infections.
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Affiliation(s)
- I Marie
- Département de médecine interne, CHU de Rouen, 1, rue de Germont, 76031 Rouen cedex, France.
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23
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Moreno D, Martínez P, Berbegal J, Femenia M. Leishmaniasis visceral en una paciente con artritis reumatoide en tratamiento con adalimumab: descripción del caso y revisión de la literatura médica. Enferm Infecc Microbiol Clin 2010; 28:261-2. [DOI: 10.1016/j.eimc.2009.03.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2009] [Revised: 03/25/2009] [Accepted: 03/27/2009] [Indexed: 10/20/2022]
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Serra I, Marín I, Morillas RM, Domènech E. Leishmaniasis visceral en paciente con hepatitis autoinmunitaria en tratamiento inmunodepresor combinado. Med Clin (Barc) 2010; 134:234-5. [DOI: 10.1016/j.medcli.2009.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Accepted: 02/05/2009] [Indexed: 01/26/2023]
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25
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Schneider P, Bouaziz JD, Foulet F, Duong T, Valeyrie Allanore L, Bagot M. Leishmaniose cutanée multifocale à Leishmania infantum sous traitement par adalimumab. Ann Dermatol Venereol 2009; 136:815-6. [DOI: 10.1016/j.annder.2009.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2008] [Accepted: 05/29/2009] [Indexed: 11/26/2022]
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26
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Leishmaniasis and biologic therapies for rheumatologic diseases. Semin Arthritis Rheum 2009; 40:e3-5. [PMID: 19782386 DOI: 10.1016/j.semarthrit.2009.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2009] [Revised: 06/30/2009] [Accepted: 07/15/2009] [Indexed: 11/21/2022]
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27
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Xynos ID, Tektonidou MG, Pikazis D, Sipsas NV. Leishmaniasis, autoimmune rheumatic disease, and anti-tumor necrosis factor therapy, Europe. Emerg Infect Dis 2009; 15:956-9. [PMID: 19523302 PMCID: PMC2727307 DOI: 10.3201/eid1506.090101] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We report 2 cases of leishmaniasis in patients with autoimmune rheumatic diseases
in Greece. To assess trends in leishmaniasis reporting in this patient
population, we searched the literature for similar reports from Europe. Reports
increased during 2004–2008, especially for patients treated with
anti–tumor necrosis factor agents.
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Affiliation(s)
- Ioannis D Xynos
- National and Kapodistrian University of Athens, Athens, Greece
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28
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Venizelos I, Tatsiou Z, Papathomas TG, Orazi A. Visceral leishmaniasis in a rheumatoid arthritis patient treated with methotrexate. Int J Infect Dis 2009; 13:e169-72. [DOI: 10.1016/j.ijid.2008.09.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2008] [Revised: 08/20/2008] [Accepted: 09/05/2008] [Indexed: 11/28/2022] Open
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Garg R, Barat C, Ouellet M, Lodge R, Tremblay MJ. Leishmania infantum amastigotes enhance HIV-1 production in cocultures of human dendritic cells and CD4 T cells by inducing secretion of IL-6 and TNF-alpha. PLoS Negl Trop Dis 2009; 3:e441. [PMID: 19468304 PMCID: PMC2680485 DOI: 10.1371/journal.pntd.0000441] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2008] [Accepted: 04/23/2009] [Indexed: 12/20/2022] Open
Abstract
Background Visceral leishmaniasis has emerged as an important opportunistic disease among patients infected with HIV-1. Both HIV-1 and the protozoan parasite Leishmania can productively infect cells of the macrophage-dendritic cell lineage. Methodology/Principal Findings Here we demonstrate that Leishmania infantum amastigotes increase HIV-1 production when human primary dendritic cells (DCs) are cocultured together with autologous CD4+ T cells. Interestingly, the promastigote form of the parasite does not modulate virus replication. Moreover, we report that amastigotes promote virus replication in both cell types. Our results indicate that this process is due to secretion of parasite-induced soluble factors by DCs. Luminex micro-beads array system analyses indicate that Leishmania infantum amastigotes induce a higher secretion of several cytokines (i.e. IL-1α, IL-2, IL-6, IL-10 and TNF-α) and chemokines (i.e. MIP-1α, MIP-1β and RANTES) in these cells. Studies conducted with pentoxifylline and neutralizing antibodies revealed that the Leishmania-dependent augmentation in HIV-1 replication is due to a higher secretion of IL-6 and TNF-α. Conclusions/Significance Altogether these findings suggest that the presence of Leishmania within DC/T-cell conjugates leads to an enhancement of virus production and demonstrate that HIV-1 and Leishmania can establish complex interactions in such a cellular microenvironment. Visceral leishmaniasis (VL) is a potentially deadly parasitic disease afflicting millions worldwide. Although itself an important infectious illness, VL has also emerged as an opportunistic disease among patients infected with HIV-1. This is partly due to the increasing overlap between urban regions of high HIV-1 transmission and areas where Leishmania is endemic. Furthermore, VL increases the development and clinical progression of AIDS-related diseases. Conversely, HIV-1-infected individuals are at greater risk of developing VL or suffering relapse. Finally, HIV-1 and Leishmania can both productively infect cells of the macrophage-dendritic cell lineage, resulting in a cumulative deficiency of the immune response. We therefore studied the effect of Leishmania infantum on HIV-1 production when dendritic cells (DCs) are cocultured with autologous CD4+ T cells. We show that amastigotes promote virus replication in both DCs and lymphocytes, due to a parasite-mediated production of soluble factors by DCs. Micro-beads array analyses indicate that Leishmania infantum amastigotes infection induces a higher secretion of several cytokines in these cells, and use of specific neutralizing antibodies revealed that the Leishmania-induced increase in HIV-1 replication is due to IL-6 and TNF-α. These findings suggest that Leishmania's presence within DC/T-cell conjugates leads to an enhanced HIV-1 production.
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Affiliation(s)
- Ravendra Garg
- Centre de Recherche en Infectiologie, Centre Hospitalier de l'Université Laval, and Faculté de Médecine, Université Laval, Québec, Québec, Canada
| | - Corinne Barat
- Centre de Recherche en Infectiologie, Centre Hospitalier de l'Université Laval, and Faculté de Médecine, Université Laval, Québec, Québec, Canada
| | - Michel Ouellet
- Centre de Recherche en Infectiologie, Centre Hospitalier de l'Université Laval, and Faculté de Médecine, Université Laval, Québec, Québec, Canada
| | - Robert Lodge
- Centre de Recherche en Infectiologie, Centre Hospitalier de l'Université Laval, and Faculté de Médecine, Université Laval, Québec, Québec, Canada
| | - Michel J. Tremblay
- Centre de Recherche en Infectiologie, Centre Hospitalier de l'Université Laval, and Faculté de Médecine, Université Laval, Québec, Québec, Canada
- * E-mail:
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Visceral leishmaniasis in a patient with psoriatic arthritis treated with infliximab: reactivation of a latent infection? Clin Rheumatol 2007; 27:541-2. [PMID: 17963018 DOI: 10.1007/s10067-007-0775-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2007] [Revised: 09/24/2007] [Accepted: 10/02/2007] [Indexed: 10/22/2022]
Abstract
Tumor necrosis factor (TNF) is a proinflammatory cytokine that plays a key role in the pathogenesis of autoimmune diseases and is an important constituent of the human immune response to infection. We report the case of a 45-year-old man with psoriatic arthritis, receiving treatment with infliximab, who presented with high-grade fever, rigor, splenomegaly, acute reactive proteins, and pancytopenia. The diagnosis of visceral leishmaniasis was established. The patient reported that his dog died from Leishmania infection 5 years ago, while he was living in an area endemic for Leishmania. The use of anti-TNF biologic agent in this patient might result in new infection or reactivation of a latent infection with Leishmania, 5 years after the exposure. A detailed current and past medical history should be obtained of every patient candidate for treatment with biologic agents, and a close monitoring is needed for serious opportunistic infections, including visceral leishmaniasis.
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Sakkas LI, Boulbou M, Kyriakou D, Makri I, Sinani C, Germenis A, Stathakis N. Immunological features of visceral leishmaniasis may mimic systemic lupus erythematosus. Clin Biochem 2007; 41:65-8. [PMID: 17991433 DOI: 10.1016/j.clinbiochem.2007.10.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2007] [Revised: 09/14/2007] [Accepted: 10/11/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Visceral leishmaniasis (VL), caused by the intracellular parasite Leishmania, can present with fever, splenomegaly, pancytopenias, hypergammaglobulinemia, and autoantibody production. These features may mimic systemic lupus erythematosus (SLE). The objective was to study features of VL that shared with and differed from SLE. DESIGN AND METHODS A small retrospective study of six patients with VL diagnosed in a University Hospital between 2001 and 2007. RESULTS All patients had cytopenias, firm splenomegaly, high acute phase reactants, and activation of the coagulation cascade. Hypergammaglobulinemia was detected in five patients. Direct Coombs test was positive in all patients, anti-nuclear antibodies were detected in five patients, anti-smooth muscle antibodies (ASMA) in four patients, and IgM rheumatoid factor (RF) in four patients. Anti-dsDNA antibodies were detected in one patient and IgM anti-cardiolipin antibodies were detected in one patient. CONCLUSION Autoantibodies are frequently detected in VL and may mimic SLE, but massive firm splenomegaly, very high acute phase reactants, and activation of coagulation system with high D-dimers point toward infection.
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Affiliation(s)
- Lazaros I Sakkas
- Department of Internal Medicine and Rheumatology, Thessaly University School of Medicine and University Hospital of Larisa, Larisa 41110, Greece.
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Nylén S, Sacks D. Interleukin-10 and the pathogenesis of human visceral leishmaniasis. Trends Immunol 2007; 28:378-84. [PMID: 17689290 DOI: 10.1016/j.it.2007.07.004] [Citation(s) in RCA: 278] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2007] [Revised: 06/18/2007] [Accepted: 07/24/2007] [Indexed: 11/21/2022]
Abstract
The mechanisms underlying the failure to control the growth and systemic spread of Leishmania parasites in human visceral leishmaniasis (VL) are not well understood. Although the absence of antigen-specific Th1 responses in the peripheral blood mononuclear cells from VL patients is thought to be causally related to disease progression, the finding that these patients also express elevated interferon-gamma mRNA in lesional tissue, as well as elevated serum levels of proinflammatory cytokines, suggests that their immunological defect cannot be explained simply by immune tolerance or Th2 polarization. As a possible homeostatic mechanism to control persistent infection-induced inflammation, elevated levels of the regulatory cytokine interleukin (IL)-10 have been reported repeatedly in clinical studies of VL. Here, we review the studies with relevance to immune responses in human VL and highlight the central role that IL-10 might have in the pathogenesis of VL and as a target for immune-based therapy.
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Affiliation(s)
- Susanne Nylén
- Laboratory of Parasitic Diseases, Bldg 4 RmB1-12, National Institute of Allergy and Infectious Diseases, 4 Center Drive MSC0425, Bethesda, MD 20892-0425, USA
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2007. [DOI: 10.1002/pds.1374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Seiderer J, Brand S, Dambacher J, Pfennig S, Jürgens M, Göke B, Ochsenkühn T. Adalimumab in patients with Crohn's disease--safety and efficacy in an open-label single centre study. Aliment Pharmacol Ther 2007; 25:787-96. [PMID: 17373917 DOI: 10.1111/j.1365-2036.2007.03253.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIM To evaluate the efficacy and safety of adalimumab, a human antitumour necrosis factor-alpha antibody, in induction and maintenance of remission in patients with Crohn's disease either refractory or intolerant to infliximab in a single centre cohort. METHODS Sixteen Crohn's disease patients received 160 mg adalimumab subcutaneously in week 0, followed by 80 mg every other week. Clinical response was assessed based on Crohn's disease activity index and laboratory parameters (leukocyte count, C-reactive protein). In all patients genotyping for CARD15 variants and the +1059G/C polymorphism in the C-reactive protein gene was performed. RESULTS In 10 of 16 patients (63%) treated with adalimumab, remission (CDAI score <150) was induced for at least 8 weeks independent of CARD15 or +1059G/C CRP status. In six of these 10 patients ongoing remission is observed now for more than 24 weeks. Adalimumab significantly decreased C-reactive protein serum levels and Crohn's disease activity index. There was one serious complication (fungal pneumonia). Six patients intermittently developed minor dermatological problems resolving after topical therapy. Otherwise, treatment was generally well tolerated. CONCLUSION Adalimumab can induce and maintain remission in patients with moderate to severe Crohn's disease intolerant or refractory to infliximab. Further experience from larger cohorts is required to evaluate dose regimen and safety profiles in Crohn's disease therapy.
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Affiliation(s)
- J Seiderer
- Department of Internal Medicine II, University-Hospital Munich-Grosshadern, Munich, Germany
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