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Cutaneous leishmaniasis with histopathologic pattern of non-necrotizing granulomatous dermatitis in patients treated with adalimumab

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Cutaneous leishmaniasis with histopathologic pattern of non-necrotizing granulomatous dermatitis in patients treated with adalimumab
Alberto Romero-Maté1 MD, Diego Martínez-Sánchez1 MD, Juan C Tardío2, Amalia Moreno-Torres2, Carmen García-Donoso1 MD, Marta Aguado-Lobo1, Pablo Espinosa-Lara1, Jesús Borbujo1 MD
Dermatology Online Journal 18 (9): 7

1. Department of Dermatology
2. Department of Pathology, Hospital Universitario de Fuenlabrada, Madrid, Spain


Human leishmaniasis produced by Leishmania infantum is endemic in Mediterranean countries. In the context of a leishmaniasis outbreak in the town of Fuenlabrada, Madrid, Spain, we had two patients with cutaneous leishmaniasis that developed non-necrotizing cutaneous granulomas. They had both been receiving anti-TNF treatment with adalimumab for rheumatic diseases. Neither of them developed visceral disease and did not require anti-TNF treatment withdrawal to control the cutaneous disease. It is well known that anti-TNF therapy is associated with opportunistic diseases, especially with those in which granuloma formation is an important part of the host defence, as in tuberculosis. We think that granuloma formation through activation of Toll-like receptor-9 and via induction of a Th17 response may be precipitated by the parasites in the dermis.


Human leishmaniasis is an infection caused by flagellated protozoa of the genus Leishmania. They are obligate intracellular parasites that selectively infect dendritic cells and macrophages. Development of cutaneous, mucocutaneous, or visceral disease depends on the Leishmania species involved and on the immune response of the host. The disease caused by Leishmania infantum is endemic in Mediterranean countries. The normal course of cutaneous leishmaniasis (CL) is spontaneous healing. In the first half of 2011, we had a community epidemic outbreak of CL in the town of Fuenlabrada, Madrid, Spain. The first patient was diagnosed in February 2011, but the symptoms began in the spring of 2010. Since then and until August 2011, 106 cases had been diagnosed. Most of them showed granulomas in the skin biopsies and in only a low percentage of them Leishmania parasites were seen on microscopic examination. Therefore, polymerase chain reaction analysis was the mainstay for the diagnosis of the majority of them. Forty-seven additional cases of leishmania infection, 7 ganglional and 40 visceral, had been identified between April 2010 and September 2011. In this context, two patients that were being treated with adalimumab developed a granulomatous dermatitis caused by L. infantum.

Case reports

Case 1

Figure 1Figure 2a
Figure 1. Patient 1. (1a) Six 2 to 4 mm, papular, erythematous, infiltrated lesions, on the medial aspect of the left leg, distributed in a linear pattern. (1b) Infiltrated, erythematous, 15 mm papule, with a central keratotic, adherent crust, on the dorsum of the left forearm.

Figures 2a and 2b. Patient 1. The epidermis is thinned and exhibits hyperkeratosis. In mid dermis there is a dense inflammatory infiltrate composed of lymphocytes and histiocytes with perivascular distribution and well-defined granulomas without necrosis. (2a. H&E x100, 2b. H&E x200)

Figure 2b

A 61-year-old woman had rheumatoid arthritis treated with adalimumab since 2006 at dose of 40 mg each other week and ongoing until July 2011. In June 2010 she presented with a group of linearly distributed, 2 to 4 mm-papular, erythematous lesions, on the medial aspect of the left leg and an infiltrated, erythematous 15 mm-papule, with a central keratotic, adherent crust, on the dorsum of the left forearm (Figure 1). Both lesions developed 10 months before we first saw her. She had no associated systemic symptoms and peripheral lymphadenopathy or hepatosplenomegaly could not be detected on physical examination. Punch biopsies of both lesions showed a dense inflammatory infiltrate composed of lymphocytes and histiocytes with perivascular distribution and granuloma formation without necrosis in the mid dermis. The overlying epidermis was thinned and exhibited hyperkeratosis with parakeratosis (Figures 2a and 2b). PAS, Giemsa, Gram, and Ziehl-Neelsen stains did not show microorganisms. Mycobacterium culture of the skin biopsy and serum tests for hepatitis B and C virus and human immunodeficiency virus were all negative. Antinuclear antibodies and anti-DNA antibodies were positive at a titre of 1/160 and 1/80 respectively. Antibodies against extractable nuclear antigens (ENA-antibodies) and angiotensin converting enzyme were negative. Polymerase-chain reaction (PCR) amplification of genomic sequences was positive for Leishmania infantum and the diagnosis of CL with non-necrotizing granulomatous dermatitis was made. Owing to the mild nature of the disease and the limited and stable course over the last 12 months, we did not consider it necessary to withdraw adalimumab and no treatment against leishmania was prescribed. Twenty-two months after the development of the disease, she remains stable, without either cutaneous or systemic progression of the infection. She was lost to follow-up in July 2011.

Case 2

Figure 3Figure 4a
Figure 3. Patient 2. An indurated, well-defined, erythematous, 30x15 mm-plaque, with two central crusts on the right thigh.

Figures 4a and 4b. Patient 2. In superficial and mid dermis there is a diffuse and dense dermal inflammatory infiltrate composed of small lymphocytes, some activated large lymphocytes, plasma cells, histiocytes, and Touton giant cells. There are poorly defined granulomas without central necrosis. (4a. H&E x40, 4b. H&E x100)

Figure 4b

A 59-year-old woman, with arterial hypertension, had plaque psoriasis and psoriatic arthritis for the last 7 years. Previous treatments included acitretin, PUVA, and methotrexate (MTX). In February 2009 she began combined treatment with adalimumab 40 mg each other week and 20 mg weekly of MTX, with good joint and cutaneous response, so treatment was ongoing. In February 2011, she noticed a plaque on the medial aspect of the right thigh that grew, without symptoms, progressively until April, when we saw her. An indurated, well-defined, erythematous, 30 x 15 mm plaque, with two central crusts, was present on her right thigh (Figure 3). She denied fever or other systemic symptoms. Physical examination did not reveal peripheral lymphadenopathy or hepatosplenomegaly. A cutaneous biopsy showed a diffuse and dense dermal inflammatory infiltrate composed of small lymphocytes, some activated large lymphocytes, plasma cells, histiocytes, and Touton giant cells. The latter formed poorly defined granulomas without central necrosis (Figures 4a and 4b). PAS, Giemsa, Gram, and Ziehl-Neelsen stains failed to show mycobacterium, fungi, or leishmania. PCR could not detect leishmania on paraffin-embedded skin, but was positive for Leishmania infantum on a second sample of fresh skin. After the diagnosis of CL, treatment with intralesional meglumine antimoniate was started, with weekly injections. After the fifth dose in August 2011, the lesion was resolved and at follow-up, five months later, in January 2012, there were no signs of recurrence. As in the other patient, treatment with adalimumab and MTX was not discontinued at any time.


The role of TNF-α in the host resistance to infection by Leishmania major has been known since the 1990s, when its protective effect was suspected to relate to its ability to activate macrophage leishmanicidal activity [1]. In recent years, it has been established in experimental murine leishmaniasis that TNF provides protective immunity against L. major [2] and that TNF is necessary to provide an adequate environment to initiate a local inflammatory response by inducing a cascade of events crucial for dendritc cell migration from skin to lymph nodes [3]. In another study, membrane-associated L. infantum antigens (MLA) induced purified macrophages from non-infected individuals to secrete the inflammatory cytokine TNF-α [4]. Also TNF-α is known to play a key role in granuloma formation [5] and anti-TNF drugs can favor the development of obligated intracellular microorganism infections.

Adalimumab is a human monoclonal antibody that binds to TNF-α, blocking its biological activity. Theoretically, an anti-TNF-treated patient would be prone to develop a more severe Leishmania infection than someone not exposed to anti-TNF drugs because granuloma formation should be inhibited. Visceral leishmaniasis has been increasingly reported in recent years in some patients treated with infliximab [6-10], adalimumab [11] (including one patient who developed a macrophage activation syndrome [12]), or etanercept [13]. But also CL has been reported in patients treated with infliximab [14] or adalimumab [15, 16], showing atypical features. These atypical CL features included a relapsing [14], a pseudo-lymphomatoid form [15], and multifocal disease [16]. In all of them anti-TNF agents were withdrawn to resolve the disease.

Our cases are unique because CL with a granulomatous dermatitis pattern has not been previously described in anti-TNF treated patients. The first one had multifocal disease with 6 papules. After noticing that she had long-standing, stable disease, no active treatment, but close observation with frequent visits was scheduled. No clinical changes were seen for the next 6 months. The second patient had the typical “oriental sore” on the right thigh that disappeared after five intralesional injections of meglumine antimoniate. We did not withdraw adalimumab in either patient, because of the local nature of the disease, their good general health, and the great response of the underlying disease to adalimumab.

Why did our patients develop granulomas? If the infection depends on both the parasite and the host, both hosts were under anti-TNF therapy, the second with associated MTX; their ability to develop granulomas should be impaired. We consider that the parasite itself enhances granuloma formation. Toll-like receptor (TLR) signalling pathway is the first system that defends against Leishmania, triggering NF-κB expression and promoting the transcription of pro-inflammatory cytokines [17]. Recently TLR9, which recognizes DNA fragments, has been described in an increased proportion inside CL granulomas produced by L. braziliensis; the authors conclude that TLR9 is important both to develop and to maintain granulomas [17]. It is likely that some DNA fragments of leishmania can bind to TLR9 on macrophages and dendritic cells, causing their activation and acting in a similar way as it has been described in the mycobacteria elicited pulmonary granulomatous response in mouse models [18]. TLR9 associated with the dendritic cell-derived Notch ligand delta-like 4 would upregulate Th17 activation and increase IL-17A secretion. IL-17A would promote neutrophil recruitment and survival and regulation of granuloma formation, mediated by neutrophils, depending on chemokine signaling through CXCR3 (chemokine (C-X-C motif) receptor). Another recent report stresses the essential role of IL-17A, produced by TCR γδ T cells, in the formation of granulomas in the lung after mycobacterial infection. The IL17A would participate in the maturation of granulomas stimulating the migration of cells towards bacillus Calmette-Guerin (BCG)-infected macrophages via CCL2 (chemokine (C-C motif) ligand 2) induction in addition to promoting cell binding in the granulomas through ICAM-1(Inter-Cellular Adhesion Molecule 1) and LFA-1 (Lymphocyte function-associated antigen 1) induction [19]. The authors suggest that cell contact between infected macrophages and TCR γδ T cells, rather than secreted factors is required for the IL17A-dependent induction of the adhesion molecules. This is supported by the fact that addition of monoclonal antibodies to TNF-α, a TCR γδ T cell-derived cytokine, failed to suppress the induction of these adhesion molecules [19]. The involvement of IL17A in granuloma formation is not restricted to bacterial infection. Infection of mice with S. mansonii after immunization induces severe granulomas and the IL17A-producing cells were S. mansonii Ag specific T-cells [20]. So we think that in our patients, leishmania DNA fragments could have binded to TLR-9 in macropahges to enhance a Th17 response, secretion of IL-17A, and granuloma formation through neutrophil recruitment and expression of adhesion molecules ICAM-1 and LFA-1 This in turn would maintain macrophages in the granulomas, favoring granuloma maturation, without the intervention of the knocked-out TNF-α.

A recent article that describes the published cases of leishmaniasis in patients treated with anti-TNF drugs in Europe, reports 19 cases, 5 of them cutaneous, 2 mucocutaneous, and 12 visceral [21]. Seventeen were being treated with monoclonal antibodies (infliximab or adalimumab), one with etanercept switched to infliximab, and one with etanercept only. This is an 8-fold increase of opportunistic leishmaniasis with anti-TNF treatment [21].

We report two patients that developed CL while being treated with TNF-α blockers. They were able to mount an immune response to L. infantum with granuloma formation. This likely prevented the dissemination of the infestation and visceral disease. One of them had multifocal disease. Although CL is a self-limited disease, in the literature, patients are usually treated; in addition, anti-TNF-α biologics are generally discontinued in those being treated with this therapy. This did not appear necessary in our patients.


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