title: Leishmaniasis during anti-tumor necrosis factor therapy: report of 4 cases and review of the literature (additional 28 cases).
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.
authors.affiliation: Department of Rheumatic Diseases, Hospital Júlio Muller/UFMT, Mato Grosso, Brazil.
authors.forename: Luiz Sergio
authors.initials: LS
authors.lastname: Guedes-Barbosa
authors.forename: Izaias
authors.initials: I
authors.lastname: Pereira da Costa
authors.forename: Vander
authors.initials: V
authors.lastname: Fernandes
authors.forename: Licia Maria
authors.initials: LM
authors.lastname: Henrique da Mota
authors.forename: Ivana
authors.initials: I
authors.lastname: de Menezes
authors.forename: Morton
authors.initials: M
authors.lastname: Aaron Scheinberg
mesh_terms: D000328:Adult; D000368:Aged; D018501:Antirheumatic Agents / Q000009:adverse effects*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy* / Q000276:immunology; D002648:Child; D005260:Female; D006801:Humans; D016867:Immunocompromised Host; D007896:Leishmaniasis / Q000276:immunology*; D008297:Male; D008875:Middle Aged; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*
chemical_list: D018501:Antirheumatic Agents; D014409:Tumor Necrosis Factor-alpha
keywords: Anti-tumor necrosis factor agents; Immunosuppression; Leishmaniasis