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.

Figure 1. Lesion on the left ankle of patient 1 before therapy at biopsy (1A); histology of the initial biopsy (1B) showed granulated tissue and signs of venous stasis (HE x400); kDNA-PCR analysis amplified a 120-bp fragment (1C); the lesion after completing anti-leishmanial and antimicrobial therapy is shown (1D).

Figure 2. Induration and crusting on the nasal areas of the lesion of patient 2 at admission (2A); results of histology (2B) (HE x400); PCR-RFLP (2C) showing the 80 and the 40-bp fragments, and the lesion after completion of Leishmania-specific therapy is shown (2D).