Case and Research Letters
Cutaneous Leishmaniasis in a Patient Receiving Infliximab for Psoriatic Arthritis: Treatment with Cryotherapy and Intralesional Meglumine Antimonate
Leishmaniasis cutánea en un paciente con artritis psoriásica tratado con infliximab: tratamiento con crioterapia y Glucantime® intralesional
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Català, M.A. Barnadas, C. Muñoz, L. Puig" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Català" "email" => array:1 [ 0 => "acatala@santpau.cat" ] "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" => "M.A." "apellidos" => "Barnadas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "C." "apellidos" => "Muñoz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "L." "apellidos" => "Puig" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Microbiología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Leishmaniasis cutánea en un paciente con artritis psoriásica tratado con infliximab: tratamiento con crioterapia y Glucantime® intralesional" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 712 "Ancho" => 951 "Tamanyo" => 293052 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histologic examination of a biopsy specimen from the edge of the ulcer showed a mixed inflammatory infiltrate with lymphocytes, histiocytes, and several macrophages with intracellular and extracellular amastigotes (red arrows) (hematoxylin-eosin, original magnification ×4).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We report the case of a 33-year-old man referred to our department with a skin ulcer that had appeared 1 year earlier on the left posterior axillary fold. His medical history was remarkable for chronic hepatitis B infection being treated with adefovir and for psoriatic arthritis, under treatment with leflunomide 20<span class="elsevierStyleHsp" style=""></span>mg/d, prednisone 5<span class="elsevierStyleHsp" style=""></span>mg/d, and infliximab 5<span class="elsevierStyleHsp" style=""></span>mg/kg every 8 weeks for the past 2 years. Physical examination revealed an ulcerated plaque measuring 9<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>cm and several erythematous-scaling papules measuring 1 to 2<span class="elsevierStyleHsp" style=""></span>cm on and around the plaque (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). There was no evidence of enlarged lymph nodes, liver, or spleen on palpation. Histologic examination showed a mixed inflammatory infiltrate with lymphocytes, histiocytes, and some macrophages with intracellular and extracellular <span class="elsevierStyleItalic">Leishmania</span> amastigotes (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Two additional biopsies were performed to complete the study. Giemsa staining of one of the biopsy specimens showed scarce amastigotes and culture of the other specimen was positive for <span class="elsevierStyleItalic">Leishmania</span> species. The subtype could not be identified. Mycobacterial culture was negative and the fungal culture was positive for <span class="elsevierStyleItalic">Candida albicans</span>. Serology showed a <span class="elsevierStyleItalic">Leishmania</span> antibody titer of 1:80. No parasite material was detected by Giemsa stains or culture of bone marrow aspirate smears. The organs did not appear enlarged on abdominal ultrasound and the blood workup showed mild neutropenia (1.64<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/L) and thrombocytopenia (127<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/L); the results of the liver and kidney function tests were normal.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Following confirmation of the diagnosis of cutaneous leishmaniasis, infliximab therapy was discontinued and treatment was started with intralesional pentavalent antimonial injections and superficial cryotherapy (9 sessions over 2.5 months). Intralesional meglumine antimoniate (MA) injections (4-8<span class="elsevierStyleHsp" style=""></span>mL) were administered every 1 or 2 weeks depending on the patient's tolerance. The total dose administered on completion of treatment was 44<span class="elsevierStyleHsp" style=""></span>mL. The patient was also prescribed itraconazole 100<span class="elsevierStyleHsp" style=""></span>mg/d for a month to treat the <span class="elsevierStyleItalic">C albicans</span> infection identified by culture. The ulcer healed completely after 3 months of treatment. To achieve better control of the patient's arthritis, he was prescribed etanercept 50<span class="elsevierStyleHsp" style=""></span>mg/wk, abatacept 750<span class="elsevierStyleHsp" style=""></span>mg/mo, and golimumab 50<span class="elsevierStyleHsp" style=""></span>mg/mo. He has been taking this medication for 2.5 years and there has been no recurrence of the cutaneous leishmaniasis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B).</p><p id="par0015" class="elsevierStylePara elsevierViewall">Tumor necrosis factor is a proinflammatory cytokine that has been implicated in the pathogenesis of inflammatory disorders and immune responses to various infections, particularly those caused by intracellular pathogens.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleItalic">Leishmania</span> species are obligate intracellular parasites of macrophages and to control infection, it is necessary to active these cells and induce the formation of granulomas. Opportunistic <span class="elsevierStyleItalic">Leishmania</span> infections can occur following the reactivation of a latent, previously undetected, infection or they can develop as a primary infection during immunosuppressive treatment. Of the cases reported in the literature of cutaneous or mucocutaneous leishmaniasis associated with anti-TNF drugs (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>),<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–9</span></a> infliximab was being used at the time of diagnosis in 5 cases. All of the other patients were receiving adalimumab.We did not identify any cases of treatment with etanercept. Furthermore, all the patients described in the above reports either lived in areas where <span class="elsevierStyleItalic">Leishmania</span> species are very common or had travelled to <span class="elsevierStyleItalic">Leishmania</span>-endemic areas. Pentavalent antimonials at a dosage of 20<span class="elsevierStyleHsp" style=""></span>mg/kg/d for 20 days are recommended by the World Health Organization as the first-line treatment of localized cutaneous leishmaniasis (1-10 skin lesions with no evidence of systemic involvement).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> However, many patients do not complete treatment because of the need for daily intramuscular injections, the duration of treatment, and its adverse effects. Several alternatives have been proposed, including liposomal amphotericin B, miltefosine, allopurinol, azoles, paromomycin, dapsone, and azithromycin.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Asilian et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> reported good results for cryotherapy combined with intralesional MA, with higher cure rates observed for the combined regimen (90.9%) than for cryotherapy (57.15%) or MA (55.63%) alone. The use of intralesional MA allows the total dose—and consequently the adverse effects—to be reduced. This treatment option yielded good results in our patient, although it should be noted that even though we used lower doses that would have been required with intramuscular MA, our patient still experienced adverse effects in the form of tachycardia, headache, and chest pain. The effects of treatment with itraconazole must also be taken into account. In conclusion, we highlight the importance of considering the possibility of cutaneous or visceral leishmaniasis in patients treated with anti-TNF drugs in <span class="elsevierStyleItalic">Leishmania</span>-endemic areas. We also recommend considering MA combined with cryotherapy as a more effective and less toxic option than intramuscular MA.</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: Català A, Barnadas MA, Muñoz C, Puig L. Leishmaniasis cutánea en un paciente con artritis psoriásica tratado con infliximab: tratamiento con crioterapia y Glucantime® intralesional. Actas Dermosifiliogr. 2014;105:714–716.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 795 "Ancho" => 1301 "Tamanyo" => 143285 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cutaneous lesions before (A) and after (B) treatment.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 712 "Ancho" => 951 "Tamanyo" => 293052 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histologic examination of a biopsy specimen from the edge of the ulcer showed a mixed inflammatory infiltrate with lymphocytes, histiocytes, and several macrophages with intracellular and extracellular amastigotes (red arrows) (hematoxylin-eosin, original magnification ×4).</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: AS, ankylosing spondylitis; CL, cutaneous leishmaniasis; MCL, mucocutaneous leishmaniasis; PA, psoriatic arthritis; RA, rheumatoid arthritis; TNF, tumor necrosis factor.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Case No. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Age, y/Sex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Primary Disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Type of Leishmaniasis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Anti-TNF Drug (Treatment Duration) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Other Immunosuppressants \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Authors (Year) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infliximab (12 mo) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Methotrexate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Liposomal amphotericin B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Xynos et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> (2009) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adalimumab (24 mo) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Methotrexate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Liposomal amphotericin B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Schneider et al.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> (2009) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">56/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MCL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adalimumab (2 mo) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Methotrexate, cortiocsteroids, infliximab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Meglumine antimoniate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Baltà-Cruz et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> (2009) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infliximab (48 mo) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Not reported \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1. Miltefosine2. Meglumine antimoniate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mueller et al.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> (2009) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MCL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adalimumab (2 mo) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Corticosteroids, methotrexate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Liposomal amphotericin B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Franklin et al.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> (2009) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infliximab (13 mo) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Corticosteroids \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Meglumine antimoniate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hakimi et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> (2010) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infliximab (0.25 mo) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Corticosteroids, methotrexate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Liposomal amphotericin B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Zanger et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> (2011) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adalimumab (12 mo) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Methotrexate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Meglumine antimoniate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gomes et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> (2012) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">66/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infliximab (25 mo) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Methotrexate, corticosteroids \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Meglumine antimoniate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">García-Castro et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> (2012) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infliximab (48 mo) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Leflunomide, corticosteroids \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Meglumine antimoniate + cryotherapy + itraconazole \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Current case \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab549031.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Cases of Cutaneous and Mucocutaneous Leishmaniasis Associated With Anti-Tumor Necrosis Factor Drugs.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Leishmaniasis, autoimmune rheumatic disease, and anti-tumor necrosis factor therapy, Europe" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 2 | 1 | 3 |
| 2024 Octubre | 74 | 36 | 110 |
| 2024 Septiembre | 87 | 29 | 116 |
| 2024 Agosto | 104 | 42 | 146 |
| 2024 Julio | 73 | 33 | 106 |
| 2024 Junio | 85 | 36 | 121 |
| 2024 Mayo | 63 | 37 | 100 |
| 2024 Abril | 90 | 27 | 117 |
| 2024 Marzo | 63 | 29 | 92 |
| 2024 Febrero | 53 | 35 | 88 |
| 2024 Enero | 46 | 33 | 79 |
| 2023 Diciembre | 53 | 16 | 69 |
| 2023 Noviembre | 54 | 30 | 84 |
| 2023 Octubre | 58 | 34 | 92 |
| 2023 Septiembre | 44 | 27 | 71 |
| 2023 Agosto | 40 | 14 | 54 |
| 2023 Julio | 44 | 33 | 77 |
| 2023 Junio | 41 | 20 | 61 |
| 2023 Mayo | 61 | 18 | 79 |
| 2023 Abril | 40 | 16 | 56 |
| 2023 Marzo | 42 | 25 | 67 |
| 2023 Febrero | 54 | 16 | 70 |
| 2023 Enero | 29 | 28 | 57 |
| 2022 Diciembre | 55 | 33 | 88 |
| 2022 Noviembre | 38 | 18 | 56 |
| 2022 Octubre | 27 | 21 | 48 |
| 2022 Septiembre | 17 | 34 | 51 |
| 2022 Agosto | 26 | 23 | 49 |
| 2022 Julio | 17 | 27 | 44 |
| 2022 Junio | 22 | 22 | 44 |
| 2022 Mayo | 34 | 31 | 65 |
| 2022 Abril | 59 | 37 | 96 |
| 2022 Marzo | 41 | 32 | 73 |
| 2022 Febrero | 42 | 30 | 72 |
| 2022 Enero | 36 | 38 | 74 |
| 2021 Diciembre | 17 | 28 | 45 |
| 2021 Noviembre | 40 | 40 | 80 |
| 2021 Octubre | 49 | 50 | 99 |
| 2021 Septiembre | 37 | 35 | 72 |
| 2021 Agosto | 33 | 21 | 54 |
| 2021 Julio | 30 | 29 | 59 |
| 2021 Junio | 33 | 32 | 65 |
| 2021 Mayo | 29 | 22 | 51 |
| 2021 Abril | 56 | 37 | 93 |
| 2021 Marzo | 70 | 20 | 90 |
| 2021 Febrero | 52 | 20 | 72 |
| 2021 Enero | 27 | 11 | 38 |
| 2020 Diciembre | 35 | 6 | 41 |
| 2020 Noviembre | 13 | 15 | 28 |
| 2020 Octubre | 24 | 10 | 34 |
| 2020 Septiembre | 22 | 6 | 28 |
| 2020 Agosto | 23 | 14 | 37 |
| 2020 Julio | 29 | 12 | 41 |
| 2020 Junio | 29 | 16 | 45 |
| 2020 Mayo | 24 | 18 | 42 |
| 2020 Abril | 33 | 11 | 44 |
| 2020 Marzo | 32 | 17 | 49 |
| 2020 Febrero | 5 | 0 | 5 |
| 2020 Enero | 4 | 1 | 5 |
| 2019 Diciembre | 8 | 2 | 10 |
| 2019 Noviembre | 4 | 1 | 5 |
| 2019 Octubre | 0 | 1 | 1 |
| 2019 Septiembre | 5 | 2 | 7 |
| 2019 Agosto | 8 | 1 | 9 |
| 2019 Julio | 4 | 1 | 5 |
| 2019 Junio | 4 | 1 | 5 |
| 2019 Mayo | 6 | 10 | 16 |
| 2019 Abril | 2 | 1 | 3 |
| 2019 Marzo | 4 | 6 | 10 |
| 2019 Febrero | 2 | 0 | 2 |
| 2019 Enero | 4 | 0 | 4 |
| 2018 Diciembre | 2 | 0 | 2 |
| 2018 Noviembre | 2 | 0 | 2 |
| 2018 Octubre | 3 | 0 | 3 |
| 2018 Septiembre | 5 | 0 | 5 |
| 2018 Junio | 0 | 1 | 1 |
| 2018 Marzo | 0 | 2 | 2 |
| 2018 Febrero | 22 | 3 | 25 |
| 2018 Enero | 31 | 4 | 35 |
| 2017 Diciembre | 39 | 7 | 46 |
| 2017 Noviembre | 29 | 6 | 35 |
| 2017 Octubre | 27 | 6 | 33 |
| 2017 Septiembre | 26 | 5 | 31 |
| 2017 Agosto | 26 | 7 | 33 |
| 2017 Julio | 29 | 8 | 37 |
| 2017 Junio | 27 | 9 | 36 |
| 2017 Mayo | 41 | 3 | 44 |
| 2017 Abril | 19 | 7 | 26 |
| 2017 Marzo | 21 | 25 | 46 |
| 2017 Febrero | 24 | 11 | 35 |
| 2017 Enero | 26 | 6 | 32 |
| 2016 Diciembre | 32 | 17 | 49 |
| 2016 Noviembre | 33 | 18 | 51 |
| 2016 Octubre | 37 | 17 | 54 |
| 2016 Septiembre | 36 | 3 | 39 |
| 2016 Agosto | 1 | 4 | 5 |
| 2016 Julio | 4 | 1 | 5 |
| 2016 Junio | 8 | 0 | 8 |
| 2016 Mayo | 6 | 1 | 7 |
| 2016 Abril | 6 | 1 | 7 |
| 2016 Marzo | 4 | 0 | 4 |
| 2016 Febrero | 6 | 1 | 7 |
| 2016 Enero | 14 | 4 | 18 |
| 2015 Diciembre | 23 | 1 | 24 |
| 2015 Noviembre | 15 | 0 | 15 |
| 2015 Octubre | 13 | 1 | 14 |
| 2015 Septiembre | 10 | 1 | 11 |
| 2015 Agosto | 8 | 2 | 10 |
| 2015 Julio | 42 | 6 | 48 |
| 2015 Junio | 37 | 4 | 41 |
| 2015 Mayo | 59 | 14 | 73 |
| 2015 Abril | 43 | 7 | 50 |
| 2015 Marzo | 38 | 5 | 43 |
| 2015 Febrero | 47 | 3 | 50 |
| 2015 Enero | 22 | 3 | 25 |
| 2014 Diciembre | 39 | 6 | 45 |
| 2014 Noviembre | 28 | 9 | 37 |
| 2014 Octubre | 31 | 6 | 37 |
| 2014 Septiembre | 21 | 6 | 27 |
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