Letter to the Editor
Aggressive cutaneous leishmaniasis in a patient with multiple sclerosis treated with fingolimod
Leishmaniasis cutánea agresiva en paciente con esclerosis múltiple tratada con fingolimod
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Hernández Clares, P. Sánchez Pedreño, E. García Vazquez, E. Carreón Guarnizo, J.E. Meca Lallana" "autores" => array:5 [ 0 => array:4 [ "nombre" => "R." "apellidos" => "Hernández Clares" "email" => array:1 [ 0 => "rociohernandezclares@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "P." "apellidos" => "Sánchez Pedreño" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "García Vazquez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "E." "apellidos" => "Carreón Guarnizo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "J.E." "apellidos" => "Meca Lallana" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Unidad de Esclerosis Múltiple, Servicio de Neurología, Hospital Virgen de la Arrixaca, Murcia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Virgen de la Arrixaca, Murcia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Medicina Infecciosa, Hospital Virgen de la Arrixaca, Murcia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Leishmaniasis cutánea agresiva en paciente con esclerosis múltiple tratada con fingolimod" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1097 "Ancho" => 1463 "Tamanyo" => 577957 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Biopsy of the lesion with haematoxylin and eosin stain, revealing a lymphoplasmacytic inflammatory infiltrate with non-caseating granulomatomas and amastigotes (circle).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cutaneous leishmaniasis caused by <span class="elsevierStyleItalic">Leishmania infantum</span> is a parasitic disease which is widely disseminated in some areas of Spain. Its most frequent manifestation is a papule or isolated, self-limiting nodule, also known as oriental sore. However, in immunocompromised patients, the condition's effects are more extensive and progressive, and progression is slower, potentially leading to systemic involvement.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> We present a case of aggressive cutaneous leishmaniasis in a patient with relapsing-remitting multiple sclerosis (RRMS) treated with fingolimod. Our hypothesis is that the aggressiveness of the disease was due to fingolimod-induced lymphopaenia.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Our patient is a 32-year-old white woman diagnosed with RRMS in 2009, who had been receiving fingolimod at a daily dose of 0.5<span class="elsevierStyleHsp" style=""></span>mg for 25 months. She was neurologically stable from treatment onset, displaying grade III maintained lymphopaenia (absolute lymphocyte count <500<span class="elsevierStyleHsp" style=""></span>cells/mm<span class="elsevierStyleSup">3</span>). The patient complained of a painful papule on the rim of the right auricle, which had expanded over the following months to cover the whole ear, becoming granulomatous and infiltrative. She also presented associated painful cervical adenopathies. The patient had no systemic symptoms; the physical examination yielded normal results. A biopsy of the lesion revealed a lymphoplasmacytic inflammatory infiltrate with non-caseating granulomatomas and amastigotes (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>); PCR was positive for <span class="elsevierStyleItalic">Leishmania infantum</span>. Treatment was started with intralesional amphotericin B, which was subsequently administered intravenously due to lack of response.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The development of new immunosuppressants for the treatment of MS has led to more effective disease control, but involves a higher risk of infectious complications associated with immunosuppression.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> Fingolimod, the first oral therapy for RRMS, acts by preventing the migration of lymphocytes from the lymph nodes, selectively affecting T cells expressing the homing receptor CCR7, such as CD4+ and naïve CD8+, and central memory T cells.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> This action mechanism causes lymphopaenia due to selective lymphocyte redistribution with preserved immunological memory; therefore, it does not initially translate into an increased risk of opportunistic infections associated with cellular immunosuppression.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> Although clinical trials performed before its approval for treating MS did not show a stronger association with infections in general, or opportunistic infections in particular, than treatment with placebo or interferon, the literature does include some isolated cases.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">5–7</span></a> In our patient, the progression of infection, its aggressiveness, and the involvement at a local level, with associated adenopathies and the need for intravenous treatment, suggest that persistent lymphopaenia associated with fingolimod may increase the risk and aggressiveness of opportunistic infections in immunocompromised patients.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Hernández Clares R, Sánchez Pedreño P, García Vazquez E, Carreón Guarnizo E, Meca Lallana JE. Leishmaniasis cutánea agresiva en paciente con esclerosis múltiple tratada con fingolimod. Neurología. 2018;33:348–349.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1097 "Ancho" => 1463 "Tamanyo" => 577957 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Biopsy of the lesion with haematoxylin and eosin stain, revealing a lymphoplasmacytic inflammatory infiltrate with non-caseating granulomatomas and amastigotes (circle).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis and treatment of leishmaniasis: clinical practice guidelines by the Infectious Diseases Society of America (IDSA) and the American Society of Tropical Medicine and Hygiene (ASTMH)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N. 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| 2020 August | 23 | 11 | 34 |
| 2020 July | 16 | 10 | 26 |
| 2020 June | 25 | 13 | 38 |
| 2020 May | 20 | 5 | 25 |
| 2020 April | 27 | 2 | 29 |
| 2020 March | 20 | 4 | 24 |
| 2020 February | 22 | 9 | 31 |
| 2020 January | 26 | 8 | 34 |
| 2019 December | 26 | 10 | 36 |
| 2019 November | 22 | 9 | 31 |
| 2019 October | 11 | 4 | 15 |
| 2019 September | 20 | 4 | 24 |
| 2019 August | 8 | 1 | 9 |
| 2019 July | 21 | 12 | 33 |
| 2019 June | 45 | 19 | 64 |
| 2019 May | 93 | 29 | 122 |
| 2019 April | 29 | 21 | 50 |
| 2019 March | 16 | 3 | 19 |
| 2019 February | 11 | 13 | 24 |
| 2019 January | 5 | 0 | 5 |
| 2018 December | 1 | 1 | 2 |
| 2018 November | 5 | 6 | 11 |
| 2018 October | 9 | 11 | 20 |
| 2018 September | 8 | 0 | 8 |
| 2018 August | 8 | 0 | 8 |
| 2018 July | 17 | 1 | 18 |
| 2018 June | 19 | 0 | 19 |
| 2018 May | 6 | 1 | 7 |
Show all
