Reactivation of Cutaneous Leishmaniasis in a Rheumatoid Arthritis Patient Undergoing Tocilizumab Treatment.
Regina Maia de Souza, Felipe Francisco Tuon, Antônio Carlos Nicodemo et al.
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Case in brief
A 62-year-old Brazilian woman with longstanding rheumatoid arthritis developed a painful ulcerative lesion on her right leg one month after starting tocilizumab. Molecular testing identified Leishmania (Viannia) braziliensis, consistent with reactivation of cutaneous leishmaniasis. Tocilizumab was stopped, and liposomal amphotericin B was begun but discontinued because of kidney and liver toxicity. The lesion gradually healed after immunosuppression was withdrawn, despite incomplete antiparasitic treatment. Secondary prophylaxis with liposomal amphotericin B was later started with close monitoring; no recurrence was reported during follow-up.
What made this case unusual
The lesion healed after withdrawal of immunosuppression despite interruption of antiparasitic treatment for toxicity, although secondary prophylaxis was subsequently initiated.
Diagnostic / clinical pearl
In patients from leishmaniasis-endemic areas receiving immunosuppression, a new ulcerative lesion should prompt consideration of reactivation and molecular testing where appropriate.
Why it matters
A history of prior leishmaniasis may be clinically relevant when selecting or monitoring immunosuppressive therapy.