CASE REPORT Visceral leishmaniasis in a patient with psoriatic arthritis treated with infliximab: reactivation of a latent infection? Maria G. Tektonidou & Fotini N. Skopouli Received: 4 September 2007 / Revised: 24 September 2007 / Accepted: 2 October 2007 / Published online: 26 October 2007 # Clinical Rheumatology 2007 Abstract Tumor necrosis factor (TNF) is a proinflammatory cytokine that plays a key role in the pathogenesis of autoimmune diseases and is an important constituent of the human immune response to infection. We report the case of a 45-year-old man with psoriatic arthritis, receiving treatment with infliximab, who presented with high-grade fever, rigor, splenomegaly, acute reactive proteins, and pancytopenia. The diagnosis of visceral leishmaniasis was established. The patient reported that his dog died from Leishmania infection 5 years ago, while he was living in an area endemic for Leishmania. The use of anti-TNF biologic agent in this patient might result in new infection or reactivation of a latent infection with Leishmania, 5 years after the exposure. A detailed current and past medical history should be obtained of every patient candidate for treatment with biologic agents, and a close monitoring is needed for serious opportunistic infections, including visceral leishmaniasis. Keywords Anti-TNF treatment . Leishmaniasis . Psoriatic arthritis Case report A 45-year-old man with a history of psoriatic arthritis was admitted to our hospital with a high-grade fever and rigor. The patient has suffered from arthritis in the metatarsopha- langeal joints and knees, and enthesitis of the Achilles since 2002, when he first received treatment with methotrexate 12.5 mg weekly, prednizolone 7.5 mg daily, and infliximab 3 mg/kg. Three years later, the dosage of methotrexate was increased to 15 mg weekly and the dosage of infliximab to 5 mg/kg. During the last 6 months, his disease was in remission. Fifteen days before his admission, he was complaining about high-grade fever and rigor. Treatment with clarithromycine 500 mg p.os twice daily was started, but a double quotidian fever was remained. Treatment with infliximab and methotrexate was discontinued, and the patient was admitted. He had no history of diarrhea, surgery, traveling abroad, or exposure to ill people; however, he reported that his dog had died from leishmaniasis 5 years before when we was living in an area of Athens endemic for leishmaniasis. On physical examination, no abnormal findings were found, besides a fever of 39.5°C. Laboratory tests showed high C-reactive protein (41 mg/l—normal range, 0–3 mg/l), high erythrocyte sediment rate (65 mm/h), and hyper- gammaglobulinemia with no monoclonal bands. A skin tuberculin test was negative. Chest X-ray and heart ultraso- nography were negative. Abdomen ultrasonography showed splenomegaly (14 cm). Four days later, he reported pain in the left abdomen. Computed tomography of the abdomen showed a further increase in splenomegaly (17 cm). Labo- ratory examinations showed a gradual decrease in the levels of hemoglobulin (9.6 g/dl), leukocytes (3,900/mm 3 ), and platelets (104,000/mm 3 ). Blood and urine cultures were negative. Antibodies toEBV, CMV, HBV, HCV, HIV, Toxo, Rickettsia conori, R. mooseri, and R. burnetti as well as Leishmania donovani were negative. Bone marrow aspira- tion demonstrated hemophagocytosis, while a bone marrow polymerase chain reaction was positive for Leishmania. Treatment with lyophilized amphotericin 3 mg/kg iv was administered for five consecutive days. On the third day, the fever disappeared, and the inflammatory markers fell Clin Rheumatol (2008) 27:541–542 DOI 10.1007/s10067-007-0775-y M. G. Tektonidou (*) : F. N. Skopouli Department of Internal Medicine, Euroclinic Hospital of Athens, 9 Athanasiadou str, 115 21 Athens, Greece e-mail: mtektonidou@euroclinic.gr