RESUMO
A large number of complications have been associated with rheumatoid arthritis (RA), those of infectious etiology being of special relevance. Their high incidence is closely linked to the use of immunosuppressive medication. The spectrum of agents causing opportunistic infections in patients with RA is very broad; however, there are relatively few cases of Leishmania infection, especially in patients not being treated with biological drugs.
Assuntos
Antirreumáticos/efeitos adversos , Artrite Reumatoide/tratamento farmacológico , Leishmaniose Visceral/induzido quimicamente , Metotrexato/efeitos adversos , Idoso de 80 Anos ou mais , Antirreumáticos/uso terapêutico , Humanos , Masculino , Metotrexato/uso terapêuticoRESUMO
The long-term use of novel antipsoriatic systemic biotechnological drugs may increase susceptibility to opportunistic infections. Several cases of visceral leishmaniasis have been reported in immunosuppressed individuals, including those who have been treated with tumour necrosis factor alpha (TNFα) blocking agents. Simultaneous occurrence of cutaneous and visceral involvement has been more rarely recorded in the medical literature. Herein, we describe a case of mucosal leishmaniasis occurring in a farmer living in an endemic region, who was treated with golimumab because of psoriatic arthritis. This highlights the importance of recognizing cutaneous lesions as a first indicator of possible underlying kala-azar disease.
Assuntos
Anticorpos Monoclonais/efeitos adversos , Anticorpos Monoclonais/uso terapêutico , Artrite Psoriásica/tratamento farmacológico , Leishmaniose Mucocutânea/induzido quimicamente , Leishmaniose Mucocutânea/diagnóstico , Leishmaniose Visceral/induzido quimicamente , Leishmaniose Visceral/diagnóstico , Doenças Labiais/induzido quimicamente , Doenças Labiais/diagnóstico , Infecções Oportunistas/induzido quimicamente , Infecções Oportunistas/diagnóstico , Fator de Necrose Tumoral alfa/efeitos adversos , Idoso , Biópsia , Medula Óssea/patologia , Diagnóstico Diferencial , Humanos , Leishmania donovani , Leishmaniose Mucocutânea/patologia , Leishmaniose Visceral/patologia , Doenças Labiais/patologia , Masculino , Infecções Oportunistas/patologia , Fator de Necrose Tumoral alfa/uso terapêuticoRESUMO
BACKGROUND: Visceral leishmaniasis is a disease caused by the protozoan Leishmania sp. and is transmitted by Lutzomyia longipalpis (sand fly). In renal transplant recipients, visceral leishmaniasis causes severe damage to the liver, spleen, and hematopoietic system, as well as poor outcomes for patients with transplanted kidneys. This study describes the largest series of cases of visceral leishmaniasis in renal transplant recipients, providing important information about the diagnostic routines and therapeutic strategies in this patient population. METHODS: A retrospective, descriptive study was performed to analyze the distribution and evaluate the extent of the epidemiologic, clinical, diagnostic and therapeutic aspects of 30 renal transplant recipients from endemic regions who presented with visceral leishmaniasis in the post-transplantation period. RESULTS: In this study, visceral leishmaniasis was more frequent in men (80%). The mean age of presentation was 40 ± 10.5 years. The majority of patients worked in urban areas (66.7%), cohabitated with domestic animals (90%), and were from low-income households. In 73.3% of cases, diagnosis was made by direct isolation of Leishmania forms. Patients were treated with liposomal amphotericin, resulting in a high degree of disease remission (80%). CONCLUSIONS: This study describes the largest series of visceral leishmaniasis in renal transplant recipients and expands clinical-epidemiological knowledge for transplantation teams to perform adequate disease management for this specific patient population.
Assuntos
Anfotericina B/uso terapêutico , Antiprotozoários/uso terapêutico , Hospedeiro Imunocomprometido , Imunossupressores/efeitos adversos , Transplante de Rim , Leishmaniose Visceral/epidemiologia , Adulto , Distribuição por Idade , Animais , Animais Domésticos , Feminino , Humanos , Nefropatias/induzido quimicamente , Nefropatias/diagnóstico , Nefropatias/tratamento farmacológico , Nefropatias/epidemiologia , Leishmania/isolamento & purificação , Leishmaniose Visceral/induzido quimicamente , Leishmaniose Visceral/diagnóstico , Leishmaniose Visceral/tratamento farmacológico , Hepatopatias/diagnóstico , Hepatopatias/tratamento farmacológico , Hepatopatias/epidemiologia , Hepatopatias/etiologia , Masculino , Pessoa de Meia-Idade , Características de Residência , Estudos Retrospectivos , Distribuição por Sexo , Esplenopatias/induzido quimicamente , Esplenopatias/diagnóstico , Esplenopatias/tratamento farmacológico , Esplenopatias/epidemiologia , TransplantadosRESUMO
Visceral leishmaniasis, in Greece, represents a relatively rare, potentially fatal clinical entity. Here we describe a case of visceral leishmaniasis infection in a 65-year old Greek male with psoriatic arthritis treated with methotrexate, who presented with high grade fever, chills, splenomegaly, pancytopenia and polyclonal hypergammaglobulinaemia. A diagnosis of visceral leishmaniasis was finally established. Visceral leishmaniasis should be included in the differential diagnosis for infections in patients receiving methotrexate for rheumatic diseases, especially in endemic areas.
Assuntos
Artrite Psoriásica/complicações , Artrite Psoriásica/tratamento farmacológico , Imunossupressores/efeitos adversos , Leishmaniose Visceral/induzido quimicamente , Metotrexato/efeitos adversos , Idoso , Humanos , Imunossupressores/uso terapêutico , Masculino , Metotrexato/uso terapêuticoAssuntos
Anticorpos Monoclonais Humanizados/efeitos adversos , Antirreumáticos/efeitos adversos , Artrite Reumatoide/tratamento farmacológico , Leishmaniose Visceral/induzido quimicamente , Adalimumab , Idoso , Anfotericina B/uso terapêutico , Antiprotozoários/uso terapêutico , Artrite Reumatoide/diagnóstico , Artrite Reumatoide/imunologia , Exame de Medula Óssea , Substituição de Medicamentos , Glucocorticoides/uso terapêutico , Humanos , Hospedeiro Imunocomprometido , Leishmaniose Visceral/diagnóstico , Leishmaniose Visceral/tratamento farmacológico , Leishmaniose Visceral/imunologia , Leishmaniose Visceral/parasitologia , Masculino , Metilprednisolona/uso terapêutico , Valor Preditivo dos Testes , Fatores de Risco , Resultado do TratamentoRESUMO
Leishmaniasis is an infectious disease caused by parasitic flagellates of the genus Leishmania. The authors present a case of 44-year-old man with Crohn's disease treated successfully with infliximab. This case report shows rare visceral leishmaniasis with cutaneous symptoms in an immunocompromised patient. Skin manifestations may occur before or after the visceral infection and they are often diverse.
Assuntos
Anti-Inflamatórios/efeitos adversos , Anticorpos Monoclonais/efeitos adversos , Doença de Crohn/tratamento farmacológico , Fármacos Gastrointestinais/efeitos adversos , Leishmaniose Cutânea/induzido quimicamente , Leishmaniose Visceral/induzido quimicamente , Adulto , Antiprotozoários/efeitos adversos , Arritmias Cardíacas/induzido quimicamente , Doença de Crohn/diagnóstico , Doença de Crohn/imunologia , Evolução Fatal , Humanos , Hospedeiro Imunocomprometido , Infliximab , Leishmaniose Cutânea/diagnóstico , Leishmaniose Cutânea/tratamento farmacológico , Leishmaniose Cutânea/imunologia , Leishmaniose Cutânea/parasitologia , Leishmaniose Visceral/diagnóstico , Leishmaniose Visceral/tratamento farmacológico , Leishmaniose Visceral/imunologia , Leishmaniose Visceral/parasitologia , Masculino , Meglumina/efeitos adversos , Antimoniato de Meglumina , Compostos Organometálicos/efeitos adversosAssuntos
Anticorpos Monoclonais Humanizados/efeitos adversos , Antirreumáticos/efeitos adversos , Artrite Reumatoide/tratamento farmacológico , Leishmaniose Visceral/induzido quimicamente , Adalimumab , Idoso , Anticorpos Monoclonais Humanizados/uso terapêutico , Antirreumáticos/uso terapêutico , Diagnóstico Diferencial , Feminino , Humanos , Leishmaniose Visceral/diagnósticoRESUMO
UNLABELLED: We report the cases of two patients treated with anti-TNF-alpha for uveitis. The first patient developed visceral leishmaniasis and the second cutaneous leishmaniasis. FIRST CASE: an 8-year-old girl was treated with corticosteroids and intravenous infliximab for juvenile idiopathic arthritis with bilateral anterior uveitis. After 12 months of treatment, she presented with fever, hepatosplenomegaly and thrombocytopenia. Visceral leishmaniasis was diagnosed, and she was treated successfully with parenteral liposomal Amphotericin-B (Ambisome(®)). Upon resolution, we re-instituted her treatment with infliximab. Second case: a 48-year-old man consulted us for severe panuveitis of the left eye with a serous retinal detachment. He was diagnosed with seronegative ankylosing spondylitis. His uveitis and arthritis were treated successfully with infliximab for 20 months, after which two cutaneous lesions appeared. The diagnosis of cutaneous leishmaniasis without visceral involvement was based on the presence of Leishmania in the skin scraping of a lesion. Intravenous infusions of infliximab were discontinued, and local treatment consisting of intralesional injections of meglumine antimonate salts (Glucantime(®)) was initiated, leading to rapid improvement. Anti-TNFα drugs are used frequently now. They appear promising in terms of efficacy, but one must carefully monitor patients for possible side effects, including infection.
Assuntos
Anticorpos Monoclonais/efeitos adversos , Leishmaniose Cutânea/induzido quimicamente , Leishmaniose Visceral/induzido quimicamente , Fator de Necrose Tumoral alfa/antagonistas & inibidores , Criança , Feminino , Humanos , Infliximab , Masculino , Pessoa de Meia-Idade , Uveíte/tratamento farmacológicoRESUMO
Atypical forms of visceral leishmaniasis associated with immunosuppressive treatment are difficult to diagnose and cause high mortality. The purpose of this report is to describe a case involving a 42-year-old patient living in a leishmaniasis-endemic area, who was undergoing immunosuppressive treatment using corticosteroids and methotrexate for pemphigus. Despite clinical and laboratory findings consistent with visceral leishmaniasis, detection of Leishmania bodies was a coincidental finding of cytological examination of bone marrow during workup for pancytopenia and associated clinical signs. This case argues in favor of systematic screening for this opportunistic parasitic disease before undertaking immunosuppressive treatment in patients presenting risk factors and consistent clinical/laboratory findings.
Assuntos
Terapia de Imunossupressão/efeitos adversos , Imunossupressores/efeitos adversos , Leishmaniose Visceral/induzido quimicamente , Pênfigo/tratamento farmacológico , Adulto , Humanos , Masculino , MarrocosRESUMO
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.
Assuntos
Anticorpos Monoclonais Humanizados/efeitos adversos , Antirreumáticos/efeitos adversos , Artrite Psoriásica/tratamento farmacológico , Leishmaniose Visceral/induzido quimicamente , Infecções Oportunistas/induzido quimicamente , Fator de Necrose Tumoral alfa/antagonistas & inibidores , Adalimumab , Idoso , Anticorpos Monoclonais Humanizados/uso terapêutico , Antirreumáticos/uso terapêutico , Biópsia , Medula Óssea/patologia , Feminino , Humanos , Leishmaniose Visceral/diagnóstico , Leishmaniose Visceral/patologia , Infecções Oportunistas/diagnóstico , Infecções Oportunistas/patologia , Pele/patologiaRESUMO
Polytope approach of genetic immunization is a promising strategy for the prevention of infectious disease as it is capable of generating effective cell mediated immunity by delivering the T cell epitopes assembled in series. Leishmaniasis is a significant world wide health problem for which no vaccine exists. In this study we have compared immunogenicity and efficacy of three types of DNA vaccines: single antigen Gp63 (Gp63/pcDNA), polytope (Poly/pcDNA) and Polytope fused with hsp70 (Poly/hsp/pcDNA) against visceral leishmaniasis in susceptible BALB/c mice. Mice vaccinated with these plasmids generated strong Th1 immune response as seen by dominating IFN-gamma over IL-10 cytokine. Interestingly, cytotoxic responses generated by polytope DNA plasmid fused with hsp70 of Leishmania donovani were significantly higher when compared to polytope and single antigen Gp63 vaccine. Challenge studies revealed that the parasite load in liver and spleen was significantly lower with Poly/hsp/pcDNA vaccination compared to other vaccines. Therefore, our study indicates that polytope DNA vaccine is a feasible, practical and effective approach for visceral leishmaniasis.
Assuntos
Epitopos/imunologia , Leishmaniose Visceral/imunologia , Leishmaniose Visceral/terapia , Metaloendopeptidases/imunologia , Vacinas de DNA/imunologia , Animais , Morte Celular , Proliferação de Células , Separação Celular , Citocinas/biossíntese , Modelos Animais de Doenças , Feminino , Proteínas de Choque Térmico HSP70/imunologia , Imunoensaio , Leishmaniose Visceral/induzido quimicamente , Leishmaniose Visceral/parasitologia , Fígado/imunologia , Fígado/parasitologia , Fígado/patologia , Camundongos , Camundongos Endogâmicos BALB C , Plasmídeos/genética , Plasmídeos/imunologia , Baço/imunologia , Baço/parasitologia , Baço/patologia , Resultado do Tratamento , VacinaçãoRESUMO
Visceral leishmaniasis (VL) is a severe disease that can develop in immunocompromised patients. Antitumor necrosis factor-alpha (TNF-alpha) treatment of rheumatoid arthritis can result in clinical benefits, but with an increased risk of opportunistic infections. Leishmania infection in patients treated with TNF-alpha antagonists is extremely rare; for this reason, we report a patient with VL after etanercept treatment who had an unfavorable outcome.
Assuntos
Artrite Reumatoide/tratamento farmacológico , Artrite Reumatoide/parasitologia , Imunoglobulina G/efeitos adversos , Fatores Imunológicos/efeitos adversos , Leishmaniose Visceral/induzido quimicamente , Artrite Reumatoide/complicações , Etanercepte , Evolução Fatal , Feminino , Grécia , Humanos , Hospedeiro Imunocomprometido , Leishmaniose Visceral/imunologia , Pessoa de Meia-Idade , Receptores do Fator de Necrose TumoralRESUMO
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 immune-suppressed. In immunodeficiency conditions, unusual forms of leishmaniasis can develop and foster the risk of a diagnostic delay and of poor response to therapy.
Assuntos
Corticosteroides/efeitos adversos , Imunossupressores/efeitos adversos , Leishmania infantum/isolamento & purificação , Leishmaniose Visceral/imunologia , Corticosteroides/imunologia , Corticosteroides/uso terapêutico , Idoso , Animais , Feminino , Humanos , Imunossupressores/uso terapêutico , Leishmaniose Visceral/induzido quimicamente , Leishmaniose Visceral/tratamento farmacológico , Leishmaniose Visceral/parasitologia , Masculino , Pessoa de Meia-Idade , Células Th1/efeitos dos fármacos , Células Th1/imunologiaAssuntos
Hepatite C Crônica/tratamento farmacológico , Interferon-alfa/efeitos adversos , Leishmaniose Visceral/induzido quimicamente , Polietilenoglicóis/efeitos adversos , Adulto , Anfotericina B/uso terapêutico , Antiprotozoários/uso terapêutico , Hepatite C Crônica/complicações , Humanos , Interferon alfa-2 , Interferon-alfa/uso terapêutico , Leishmaniose Visceral/tratamento farmacológico , Masculino , Polietilenoglicóis/uso terapêutico , Proteínas RecombinantesAssuntos
Síndrome de Behçet/complicações , Síndrome de Behçet/tratamento farmacológico , Leishmaniose Visceral/induzido quimicamente , Síndromes Mielodisplásicas/induzido quimicamente , Adulto , Antineoplásicos Alquilantes/administração & dosagem , Antineoplásicos Alquilantes/efeitos adversos , Doenças Autoimunes/complicações , Doenças Autoimunes/tratamento farmacológico , Clorambucila/administração & dosagem , Clorambucila/efeitos adversos , Humanos , Imunossupressores/administração & dosagem , Imunossupressores/efeitos adversos , Leishmaniose Visceral/diagnóstico , Leishmaniose Visceral/etiologia , Masculino , Síndromes Mielodisplásicas/diagnóstico , Síndromes Mielodisplásicas/etiologiaRESUMO
BACKGROUND: Leishmaniasis in a patient with Wegenerís disease raises the problem of amphotericin toxicity further compromising the pre-existing renal disorder. CASE REPORT: An anemic patient treated for Wegenerís disease developed visceral leishmaniasis. This renal failure patient was treated with lipid complex amphotericin B and liposomal amphotericin B. We report outcome at 10 months follow-up. DISCUSSION: The new formulations of amphotericin B allow effective treatment of visceral leishmaniasis in renal failure patients. Long-lasting results are probably favored by the interruption of immuno-suppressive therapy.
Assuntos
Anfotericina B/uso terapêutico , Granulomatose com Poliangiite/tratamento farmacológico , Leishmaniose Visceral/induzido quimicamente , Injúria Renal Aguda/tratamento farmacológico , Idoso , Anfotericina B/efeitos adversos , Anemia/tratamento farmacológico , Antibacterianos/efeitos adversos , Antibacterianos/uso terapêutico , Feminino , Seguimentos , Granulomatose com Poliangiite/complicações , Humanos , Lipossomos , Masculino , Resultado do TratamentoRESUMO
Visceral leishmaniasis, caused by Leishmania donovani, is a chronic disease with a high mortality rate. This protozoan induces a serious dysfunction of the immune system characterized by suppression of the cellular response to parasite antigens. We provide evidence for the involvement of lipids in the immunological alterations of experimental leishmaniasis. Sera obtained from 60-day-infected hamsters present increased triglyceride levels. Inhibition of cell proliferation was observed when splenocytes from normal hamsters were stimulated with concanavalin A in the presence of 3% infected hamster serum (IHS) (Control 50 +/- 3 (x10(3)) cpm; IHS 5 +/- 1 (x10(3)) cpm). This inhibition was reversed by the addition of 5 mg/ml of delipidated bovine serum albumin (BSA) to the cultures (Control 65 +/- 1 (x10(3)) cpm; IHS 75 +/- 3 (x10(3)) cpm). The inhibitory effect of IHS was demonstrable only when added to the culture simultaneously with the mitogen. This effect was not as intense on fresh, pre-activated cells or on the CTLL-2 cells. This cell line stimulated by IL-2 in the presence of IHS is only marginally inhibited (about 20% inhibition). The suppressor effect on CTLL-2 was not reversed by the addition of increasing doses of IL-2 (up to 100 U/ml) to cultures. The inhibition of the proliferative response of the CTLL-2 cells caused by IHS was also reversed by the addition of delipidated BSA. Our data suggest a role for fatty acids in the infected hamster serum-induced suppression of normal or L. donovani-infected cell proliferation.