Screening for Leishmania specific antibodies among patients with rheumatic diseases treated with biological therapy.

We have read with interest the recent Letter to the Editor: “Remembering visceral leishmaniasis as a potential trigger of haemophagocytic lymphohistiocytosis in individuals treated with anti-TNF-alpha therapy” by Nardo-Marino et al., 1 and we would like to add some comments to the letter. This letter refers to a case report by Burka et al. 2 describing a Scandinavian male patient developing hemophagocytic lymphohistiocytosis 28days after the onset of infliximab treatment. The bone marrow examination revealed the presence of Leishmania amastiotes, which was a quite surprising finding, because the patient did not have any recent travel history to leishmaniasis-endemic areas at the onset of the symptoms and had never traveled to any endemic areas outside of Europe. The majority of visceral leishmaniasis (VL) cases worldwide occur in endemic areas of Brazil, Nepal, India, and in some East African countries. In Europe, the parasitic disease is seen in the Mediterranean region. 3 As highlighted by Nardo-Marino et al., 1 VL progression induced by biologic therapy has been reported on several occasions among patients from VL endemic areas. We have recently conducted a travel questionnaire survey among arthritis patients treated with biologics in our out-patient clinic. 4 A total of 273 patients completed the questionnaire. A history of traveling to dif-ferent countries in the Mediterranean region was reported by 13%, including Portugal, Spain, Italy,