title: Reactivation of cutaneous and mucocutaneous tegumentary leishmaniasis in rheumatoid arthritis patients: an emerging problem?
abstract: Rheumatoid arthritis (RA) is a chronic condition that is frequent in patients living in tropical areas exposed to leishmaniasis. RA therapy involves immunosuppressant drugs such as methotrexate (MTX), monoclonal antibodies (mAbs) and prednisone. We report an unusual presentation of cutaneous (CL) or mucocutaneous leishmaniasis (ML) in RA patients from an endemic area of leishmaniasis. A 51-year-old woman noted a cutaneous ulcer on her left ankle during MTX and prednisone RA therapy. Initially diagnosed as a venous stasis ulcer, the aspirate of the injury revealed the presence of Leishmania DNA. A 73-year-old woman presenting non-ulcerated, infiltrated and painful erythematous nodules inside her nostrils while receiving MTX, anti-TNF mAb, and prednisone for RA, had also the aspirate of injuries showing the presence of Leishmania DNA. Both patients healed after the therapy with liposomal amphotericin. The RA therapy has changed to low-dose prednisone, without further reactivation episodes. Both cases suggest that CL or ML can reactivate after administration of an immunosuppressant for RA treatment. Therefore, immunosuppressive treatments for RA should be carefully prescribed in patients from endemic areas or with a history of CL and ML.
authors.affiliation: Universidade de São Paulo, Faculdade de Medicina, Departamento de Moléstias Infecciosas e Parasitárias, São Paulo, São Paulo, Brazil.|Universidade de São Paulo, Instituto de Medicina Tropical de São Paulo, Laboratório de Parasitologia, São Paulo, São Paulo, Brazil.
authors.forename: Regina Maia de
authors.initials: RM
authors.lastname: Souza
authors.affiliation: Universidade de São Paulo, Faculdade de Medicina, Departamento de Patologia, Laboratório de Patologia de Moléstias Transmissíveis, São Paulo, São Paulo, Brazil.|Universidade de São Paulo, Instituto de Medicina Tropical de São Paulo, Laboratório de Protozoologia, São Paulo, São Paulo, Brazil.
authors.forename: Heitor Franco de
authors.initials: HF
authors.lastname: Andrade
authors.affiliation: Universidade de São Paulo, Faculdade de Medicina, Departamento de Patologia, Laboratório de Patologia de Moléstias Transmissíveis, São Paulo, São Paulo, Brazil.
authors.forename: Maria Irma Seixas
authors.initials: MI
authors.lastname: Duarte
authors.affiliation: Universidade de São Paulo, Instituto de Medicina Tropical de São Paulo, Laboratório de Parasitologia, São Paulo, São Paulo, Brazil.
authors.forename: Lucia Maria Almeida
authors.initials: LM
authors.lastname: Braz
authors.affiliation: Fundação Oswaldo Cruz, Instituto Nacional de Infectologia Evandro Chagas, Laboratório de Pesquisa Clínica e Vigilância em Leishmanioses, Manguinhos, Rio de Janeiro, Brazil.
authors.forename: Armando de Oliveira
authors.initials: AO
authors.lastname: Schubach
authors.affiliation: Instituto Oswaldo Cruz (Fiocruz), Laboratório de Imunoparasitologia, Manguinhos, Rio de Janeiro, Brazil.
authors.forename: Fátima Conceição
authors.initials: FC
authors.lastname: Silva
authors.affiliation: Universidade de São Paulo, Faculdade de Medicina, Departamento de Moléstias Infecciosas e Parasitárias, São Paulo, São Paulo, Brazil.|Universidade de São Paulo, Instituto de Medicina Tropical de São Paulo, Laboratório de Parasitologia, São Paulo, São Paulo, Brazil.
authors.forename: Valdir Sabbaga
authors.initials: VS
authors.lastname: Amato
mesh_terms: D000368:Aged; D018501:Antirheumatic Agents / Q000009:adverse effects* / Q000627:therapeutic use; D001172:Arthritis, Rheumatoid / Q000188:drug therapy / Q000276:immunology; D016054:DNA, Protozoan / Q000032:analysis; D005260:Female; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects* / Q000627:therapeutic use; D007891:Leishmania / Q000235:genetics / Q000302:isolation & purification*; D016773:Leishmaniasis, Cutaneous / Q000175:diagnosis / Q000209:etiology*; D007897:Leishmaniasis, Mucocutaneous / Q000276:immunology; D008875:Middle Aged; D012008:Recurrence
chemical_list: D018501:Antirheumatic Agents; D016054:DNA, Protozoan; D007166:Immunosuppressive Agents