title: Visceral leishmaniasis and macrophagic activation syndrome in a patient with rheumatoid arthritis under treatment with adalimumab.
abstract: BACKGROUND
  Visceral leishmaniasis is a protozoan infection usually asymptomatic, but can progress to fatal disease in immunocompromised hosts, especially in HIV patients. Visceral leishmaniasis is rare among patients under immunosuppressive therapies, and even more among patients under anti-TNF-alpha treatment, where only four cases have been described.
  
  
  OBJECTIVE
  1) To describe a patient with rheumatoid arthritis receiving adalimumab who developed fever, pancytopenia, splenomegaly, and extreme hyperferritinemia. 2) To perform a review of the published cases of visceral leishmaniasis and anti-TNF-alpha therapy, and cases of coexisting leishmaniasis and macrophagic activation syndrome by search in PubMed (period 1991-2008).
  
  
  RESULTS
  Visceral leishmaniasis was established by bone marrow aspiration, and although there was no histological confirmation, according to HLH-2004 criteria, a secondary macrophagic activation syndrome was established. The patient had a favourable outcome.
  
  
  CONCLUSIONS
  We report herein the fifth case of visceral leishmaniasis in a patient under TNF-alpha therapy, and the first one, to our knowledge, presenting a consequent secondary macrophagic activation syndrome.
authors.affiliation: Rheumatology Section, Hospital Universitari Germans Trias I Pujol, Ctra del Canyet s/n, 08916 Badalona, Spain. anmoltre@gmail.com
authors.forename: Anna
authors.initials: A
authors.lastname: Moltó
authors.forename: Lourdes
authors.initials: L
authors.lastname: Mateo
authors.forename: Natalia
authors.initials: N
authors.lastname: Lloveras
authors.forename: Alejandro
authors.initials: A
authors.lastname: Olivé
authors.forename: Sonia
authors.initials: S
authors.lastname: Minguez
mesh_terms: D000068879:Adalimumab; D000911:Antibodies, Monoclonal / Q000008:administration & dosage / Q000009:adverse effects*; D061067:Antibodies, Monoclonal, Humanized; D018501:Antirheumatic Agents / Q000008:administration & dosage*; D001172:Arthritis, Rheumatoid / Q000150:complications / Q000188:drug therapy* / Q000276:immunology; D006801:Humans; D016867:Immunocompromised Host; D007898:Leishmaniasis, Visceral / Q000150:complications / Q000276:immunology*; D055501:Macrophage Activation Syndrome / Q000150:complications / Q000276:immunology*; D008297:Male; D008875:Middle Aged; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors
chemical_list: D000911:Antibodies, Monoclonal; D061067:Antibodies, Monoclonal, Humanized; D018501:Antirheumatic Agents; D014409:Tumor Necrosis Factor-alpha; D000068879:Adalimumab