Reactions Weekly | 2021
Immunosuppressants
Abstract
Cutaneous leishmaniasis: case report A 29-year-old man developed disseminated cutaneous leishmaniasis (CL) during treatment with triamcinolone, infliximab, ciclosporin, azathioprine, unspecified steroids and adalimumab for immunosuppressive therapy [not all routes and dosages stated; durations of treatments to reactions onset not stated]. The man, who had a relevant history of Crohn’s disease, was referred due to persistent multiple painful ulcers of 2 years duration. Originally,the cutaneous lesions were on the left arm and later involving the chest, right ear, neck and lower limbs, which had appeared during systemic therapy with IV infliximab 400mg every 8 weeks and azathioprine 50 mg/day. Following 6 and 10 months, respectively, two skin biopsies had been carried out in two different sites, with a further worsening of the cutaneous lesions understood as pathergy phenomenon. Though both histological findings indicated pyoderma gangrenosum (PG) and slow-tapered systemic unspecified steroid therapy was repeated several times, he did not report any relief. Eighteen months following the ulcers’ outbreak, infliximab and azathioprine were substituted with ciclosporin [cyclosporine] 200 mg/day and adalimumab 40mg every 2 weeks. Following a further 3 months, in the absence of clinical improvement, intralesional infiltrations of triamcinolone [triamcinolone acetonide] were carried out once a week for 2 months, with no benefit. Further, skin examination revealed well defined multiple lesions with erythematous rolled indurated margins and necrotic-purulent slough at the base and the lesions were disseminated consisting the upper limbs, lower limbs, chest and right ear. Biopsy of the lesion of the left arm revealed ulceration of the epidermis,edema, dilated vessels, and a dense nodular, multicellular, granulomatous infiltrate in the dermis and fatty tissue at full thickness. Subsequently, a diagnosis of disseminated CL was suggested. Thereafter, the diagnosis was confirmed via serological antibodies and PCR for Leishmania DNA on the tissue, demonstrating Leishmania infantum. Due to the extent of the cutaneous disease and the immunosuppression, a PCR for Leishmania DNA on peripheral blood was carried out that was negative. The man’s adalimumab and ciclosporin treatment was discontinued and he received amphotericin-B-liposomal [liposomal amphotericin B] . Further, he also received three monthly intralesional infiltrations of pentavalent antimonials resulting in complete resolution of the clinical picture and only residual scars. Treatemnt with adalimumab was not restarted. After twelve months, no recurrences were noted.