title: Anti-tumour necrosis factor-induced visceral and cutaneous leishmaniasis: case report and review of the literature.
abstract: BACKGROUND
  Leishmaniasis is a chronic protozoan disease in which organisms are found within phagolysosomes of the mononuclear phagocyte system. There are three major forms: cutaneous, mucocutaneous and visceral. We report the first case of visceral leishmaniasis with cutaneous involvement in a patient with rheumatoid arthritis treated with the anti-tumour necrosis factor (anti-TNF) adalimumab.
  
  
  OBJECTIVE
  To highlight cutaneous leishmaniasis as the first indicator of a kala-azar disease in a patient treated with anti-TNF and to review the literature on leishmaniasis in the context of anti-TNF therapy.
  
  
  METHODS
  A 59-year-old woman presented with a crusted plaque on the right elbow 34 months after the initiation of adalimumab. A cutaneous biopsy showed intracellular amastigotes. No Leishmania parasites were observed in a bone marrow aspirate, but laboratory tests showed anaemia and impaired liver function, abdominal ultrasonography showed hepatomegaly, and ELISA serology was strongly positive for Leishmania antibodies in serum and urine. Adalimumab was withdrawn and treatment combining intralesional pentavalent antimonials and liposomal amphotericin was started. Eight weeks later, the leishmaniasis had resolved.
  
  
  CONCLUSIONS
  A skin biopsy disclosing leishmaniasis should prompt tests to rule out visceral leishmaniasis, especially in an area such as the Mediterranean where the prevalence of latent Leishmania infection is high.
authors: Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
authors: Alba
authors: A
authors: Català
authors: Esther
authors: E
authors: Roé
authors: Joan
authors: J
authors: Dalmau
authors: Virginia
authors: V
authors: Pomar
authors: Carme
authors: C
authors: Muñoz
authors: Oriol
authors: O
authors: Yelamos
authors: Luis
authors: L
authors: Puig
mesh_terms: D000068879:Adalimumab; D061067:Antibodies, Monoclonal, Humanized / Q000008:administration & dosage / Q000009:adverse effects*; D018501:Antirheumatic Agents / Q000008:administration & dosage / Q000009:adverse effects*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D005260:Female; D006801:Humans; D016773:Leishmaniasis, Cutaneous / Q000175:diagnosis / Q000209:etiology*; D007898:Leishmaniasis, Visceral / Q000175:diagnosis / Q000209:etiology*; D008875:Middle Aged; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*
chemical_list: D061067:Antibodies, Monoclonal, Humanized; D018501:Antirheumatic Agents; D014409:Tumor Necrosis Factor-alpha; D000068879:Adalimumab