Methotrexate
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Methotrexate Mucosal leishmaniasis manifesting as reactivation of previous cutaneous leishmaniasis: case report
A 76-year-old man experienced mucosal leishmaniasis manifesting as reactivation of previous cutaneous leishmaniasis during treatment with methotrexate for rheumatoid arthritis. The man presented to the ENT specialist in Malta with an enlarging right vestibular lesion and recurrent episodes of epistaxis. He had a medical history of rheumatoid arthritis, Paget’s disease and osteopenia. He had been receiving methotrexate [route and dosage not stated] for rheumatoid arthritis. Despite intranasal unspecified steroids and antibiotics, there was no improvement in the lesion and the epistaxis persisted. He had no history of trauma of nose, fever, chills, rigours, weight loss, weakness, arthralgias, rashes or skin lesions. His family history was insignificant. He was a non-smoker, never had contact with dogs and had a pet healthy cat. He had a frequent travel history to England. On presentation, vital signs were normal. Nose examination revealed a 1cm diameter right vestibular ulcerated lesion. The oral cavity and left vestibule were unremarkable, and there was no cervical lymphadenopathy. Examination of the face, limbs, scalp and trunk revealed no other lesions. Abdominal examination was normal with no obvious organomegaly. Initial laboratory examination revealed a low lymphocyte count. The haemoglobin, C-reactive protein, platelet count and erythrocyte sedimentation rate were found to be normal. Liver function tests revealed a chronically elevated alkaline phosphatase secondary to Paget’s disease. Serum protein electrophoresis was normal, and HIV status was found to be negative. Rheumatoid factor was 179 [unit not stated], however this had been down-trending over the previous years. A biopsy was performed and the histology confirmed the presence of non-necrotising granulomatous inflammatory infiltration of the dermis. The infiltrate was composed of occasional multinucleated giant cells, sheets of epithelioid histiocytes, lymphocytes and plasma cells. Numerous Leishmania amastigotes were identified within the cytoplasm of the histiocytes. A PCR for Leishmania subspecies revealed the presence of Leishmania donovani complex subgenus as the causative organism [duration of treatment to reaction onset not stated]. Based on the findings, a diagnosis of mucosal leishmaniasis manifesting as reactivation of previous cutaneous leishmaniasis was considered. The man received treatment with amphotericin B. By the completion of treatment, the epistaxis stopped and the lesion had resolved completely. No recurrence was noted on follow-up visit. Grech P, et al. Leishmania donovani mucosal leishmaniasis in Malta. BMJ Case Reports 13: No. 11, 2 Nov 2020. Available from: URL: http://doi.org/10.1136/ bcr-2020-237687
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Reactions 5 Dec 2020 No. 1833
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