Infection in patients with systemic lupus erythematosus. Association with a serum inhibitor of complement-derived chemotactic activity

Multiple brain abscesses due to Listeria monocytogenes infection in a patient with systemic lupus erythematosus: A case report and literature review

AIM

To review the clinical features of systemic lupus erythematosus (SLE) complicated by central nervous system (CNS) infection due to Listeria monocytogenes.

METHOD

A patient with SLE receiving high-dose glucocorticoids combined with cyclophosphamide who developed multiple brain abscesses due to Listeria infection is described. The case is compared with known cases in a literature review.

RESULTS

A review of the literature showed that CNS infections are rare bacterial complications of SLE, but they can be a significant cause of mortality, especially those due to L. monocytogenes. The most significant risk factor for listerial meningitis is a prior history of receiving immunosuppressive therapy. At-risk patients should avoid unpasteurized milk and soft cheeses along with deli-style, ready-to-eat prepared meats, particularly poultry products. The case we report is the fifth SLE patient with multiple brain abscesses due to L. monocytogenes, and the first to be discharged with no sequelae. Timely and accurate identification and treatment of CNS infections and neuropsychiatric lupus are very important for favorable disease prognosis.

CONCLUSION

Repeated blood culture is helpful for early diagnosis, and empirical anti-infective treatment that covers L. monocytogenes is recommended for SLE patients with risk factors when CNS infection occurs. A comprehensive assessment might be helpful to distinguish CNS infections from neuropsychiatric SLE. For severe infection, the dosage of steroids does not need to be reduced immediately but can be gradually adjusted based on the results of a comprehensive evaluation of the disease.

Clinical presentations and outcomes of systemic lupus erythematosus patients with infection admitted to the intensive care unit

Objective

The objective of this article is to investigate clinical presentations and outcomes of systemic lupus erythematosus (SLE) patients with infection admitted to the intensive care unit (ICU).

Methods

SLE patients with infection, SLE patients with noninfectious causes, and non-SLE patients with infection were identified from the Cooper University Hospital Project IMPACT database between 2002 and 2010. We examined demographic data, APACHE II scores, physiologic data, laboratory data, length of stay in the ICU and hospital, and mortality of the three groups.

Results

Twenty-five SLE patients with infection, 45 SLE patients with noninfectious causes, and 1466 non-SLE patients with infection were included in the study. SLE patients with infection had higher APACHE II scores, higher maximum temperature, higher minimum and maximum heart rate (HR), lower minimum and maximum systolic blood pressure (SBP), and longer ICU length of stay in comparison to SLE patients with noninfectious causes. There were no statistical differences in white blood cell (WBC) count. SLE patients with infection had a higher mortality compared to SLE patients with noninfectious causes. There was no difference in mortality between SLE patients with infection and non-SLE patients with infection.

Conclusion

SLE patients with infection in the ICU had a higher mortality and a higher APACHE II score compared to SLE patients with noninfectious causes in the ICU. Their physiologic signs including temperature, HR, and SBP were more reflective of infection than their WBC count.

Infection-related morbidity and mortality in patients with connective tissue diseases: a systematic review

Patients suffering from connective tissue diseases (CTDs) constitute an important subgroup of immunosuppressed patients at risk for developing serious infections. Prophylactic antibiotic administration may decrease infection-related morbidity and mortality burden in patients with CTD, though one needs first to evaluate the overall effect of infection on morbidity and mortality in such patients and the presence of adequate prognostic/risk factors for infection development. Studies focusing on infection-related morbidity and mortality in patients with CTD were reviewed. Data on disease type, therapeutic regimens used, including corticosteroid dose and method of administration as well as other immunosuppressive agents, and outcome were extracted to evaluate the existence of specific treatment patterns predisposing to infection as well as infectious disease-related morbidity and mortality in patients with CTD. Thirty-nine studies focusing on infection incidence and/or outcome in patients with CTD were identified and analyzed; the majority of the reviewed studies (20) included patients with systemic lupus erythematosus (SLE). The mortality attributed to infection was 5.2%, while the overall mortality was 20%. There were no adequate data on the specific effect patterns of corticosteroid and immunosuppressant treatment on infection risk. Pneumocystis jiroveci (carinii) pneumonia, evaluated independently, exhibited significant mortality in patients with Wegener's granulomatosis, polymyositis/dermatomyositis, and SLE. In conclusion, infectious diseases are a major cause of mortality in patients with CTD. However, treatment-related factors predisposing to serious infections have not been adequately outlined. In addition, there are no data regarding the effect of prophylactic practices involving antibiotic administration in morbidity and mortality.

Purified protein derivative reaction in systemic lupus erythematosus patients. Indirect study of cellular immunity

Cutaneous anergy in SLE patients results from disease activity and/or immunosuppressive treatment (IT). The aim of this study was to evaluate purified protein derivative (PPD) reaction in SLE patients. A total of 145 patients and 20 controls were studied. Five units of PPD were applied on day 0, and skin reaction was measured after 3 (PPD1) and 6 (PPD2) days. A booster was applied (day 14), and the reaction was measured after 3 (PPD3) and 6 (PPD4) days. Non-parametric ANOVA test and unpaired Student's t-test were performed. Forty patients (group I) were inactive (MexSLEDAI < 3), receiving no IT (at least 3 months previous to the PPD test); 39 (group II) were inactive receiving IT; 24 (group III) were active without IT, and 42 (group IV) were active with IT. Active patients had lower PPD1 (group III, 1.4 +/- 0.9; group IV, 0.6 +/- 0.5) than inactive patients (group I, 8.4 +/- 2.3; group II, 5.1 +/- 1.9) and than controls (9.4 +/- 3; P < or = 0.001). Group IV had lower delayed response (PPD2 = 0.3 +/- 0.3) than inactive groups (group I, 2.6 +/- 0.9; group II, 3.1 +/- 0.8) and than controls (7.9 +/- 2.5; P < or = 0.001). Group III had lower delayed reaction (PPD2 = 1.2 +/- 0.8) than controls (P < or = 0.001). Active SLE patients, receiving or not receiving IT, had lower skin response to PPD than inactive patients and controls.

Infections in outpatients with systemic lupus erythematosus: a prospective study

The objective of this study was to assess the incidence and risk factors of infections in 200 SLE outpatients. All outpatients with active or inactive SLE without infections in the previous month were included. They were assessed every 3 months. Major infections were those requiring hospitalization and parental antibiotic therapy; minor infections required oral or topical therapy. Sociodemographic, disease activity using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), therapy and laboratory variables were evaluated. After a follow-up of 22+/-7 months, 65 (32%) patients had infections; 35% of those were major. The most common sites for infection were urinary (26%), skin (23%), systemic (12%), and vaginal (9%). At infection onset, 50 of 65 patients (77%) had disease activity, with a mean SLEDAI score of 6.1. The variables significantly associated with infection in the univariate analyses were the presence of disease activity, SLEDAI score, renal activity, prednisone dose, and IV cyclophosphamide. The only variable associated with infection in the multivariate analyses was a SLEDAI score of 4 or higher. Most infections in SLE outpatients were single, minor, non-life threatening, and associated with disease activity independently of sociodemographic and therapeutic factors.

Combination therapy: the risks of infection and tumor induction

It is clear that the rate of infection is increased in most of the more serious forms of autoimmune disease and agents such as high-dose steroids and the alkylating agents increase this risk. Other agents such as MTX, CsA, LEF, AZA and the TNF antagonists do not appear to increase the risk of infection given either alone or in combination. Similarly, the risk of malignancy in certain types of autoimmune disease appears increased. However, other than the alkylating agents, none of the agents used appear to increase this risk. The more recently released agents such as CsA, LEF and the TNF antagonists need longer durations of follow-up to substantiate this, however. It is clear that, unless they are absolutely necessary, one should avoid the alkylating agents used either alone or in combination to avoid problems with infection and malignancy. In addition, the use of steroids should be kept as low as possible to avoid infections. It is possible that the use of the more benign agents alone and in combination earlier in the disease course may help to reduce both infection and the incidence of malignancy in the long run.

Intramedullary tuberculosis manifested as Brown-Sequard syndrome in a patient with systemic lupus erythematosus

A 25-year-old girl presented with progressive deterioration of right side weakness with decreased sensation on the left trunk. She had been treated with high dose steroid due to autoimmune thrombocytopenia for 2 months. Clinical, laboratory and immunologic studies revealed that she had systemic lupus erythematosus (SLE), MRI of spinal cord showed marginal contrast enhancing and fluid containing mass in the cord of the C5-6 level, suggesting intramedullary abscess. She underwent surgery of mass removal with biopsy. The pathologic findings from cord tissues revealed numerous acid fast bacilli (AFB) in necrotic tissues. After surgery and anti-tuberculous treatment, her neurologic symptoms were markedly improved with restoration of right side motor weakness. To our knowledge, this is the first case report of intramedullary tuberculosis in a patient with SLE. Since intramedullary tuberculosis may sometimes mimic neurologic complication of SLE itself, it may pose diagnostic and therapeutic confusion for clinicians. We report a case of spinal cord tuberculosis affecting C5, 6 level which was manifested as Brown-Sequard syndrome in a patient with SLE.

Salmonella septic arthritis in systemic lupus erythematosus and other systemic diseases

Salmonella infection is an important problem in immunocompromised patients. The synovium is a particular metastatic focus of Salmonella infection and can result in many disabilities of life. Systemic lupus erythematosus (SLE) patients were highly susceptible to Salmonella infection. In the past 6 years, 41 patients with Salmonella septic arthritis have been treated in our hospital. Eleven patients had an underlying systemic disease of SLE which presented with a distinctive clinical course. Alcoholic liver disease (six cases) was another common underlying systemic disease. The most frequent predisposing articular factor was avascular necrosis (16 cases). The hip joint was the most commonly involved site. Salmonella group B was the most common serotype (30/41). Seventy-three per cent (8/11) of the SLE group had involvement of two or more joints compared with only three out of 30 patients in the non-SLE group. The sex differentiation shows a predominance of young females (10/11) in the SLE group and middle-aged males in the non-SLE group. Moreover, in the SLE group, all 11 patients shared the risk of lupus nephritis and steroid use. Ten patients had Salmonella group B bacteraemia and five had urinary tract infections simultaneously. In the non-SLE group, there were 10 patients with a history of steroid use, three with antecedent enteritis, 12 with bacteraemia, and three with necrotising fasciitis. Seven patients in each of the groups had a recurrent course. However, three patients in the non-SLE group had died during the episode of septic arthritis.

Infection in systemic lupus erythematosus

The improved survival of SLE patients since the 1950s is the result of not only better treatment, but also supportive treatment of renal failure and the wealth of antibiotics now available. Ironically, the wider use of immunosuppressives, especially the alkylating drugs, and the longer survival of patients with renal insufficiency and renal failure have made the identification and appropriate treatment of infection in SLE an ongoing challenge.

Prophylactic use of antibiotics and vaccines in patients with rheumatologic disorders

In patients with serious underlying medical conditions, preventive interventions are a prudent, cost-effective, but underused strategy that could lessen morbidity and even mortality. In particular, immunization status should be assessed in all patients with rheumatologic disorders. Tuberculin reactivity is optimally documented before initiation of steroid therapy. It is often easier (and wiser) to prevent an infection than to treat it in a compromised host.

[Oral manifestations in patients with systemic lupus erythematosus]

Forty-six patients with systemic lupus erythematosus underwent thorough dental examination to determine the frequency and severity of oral lesions and periodontal diseases. According to clinical criteria, disease was classified as severe (n = 26) or less severe (n = 20). The overall rate of mucosal involvement in the studied patients was 48%-from 54% in patients with severe disease, 40% in those with less severe disease. Patients with severe disease were found to have a higher rate of tooth loss and an increased rate of gingival inflammation. The severity of periodontal lesions correlated with alterations in the immunoglobulin pattern, particularly with an increase in gamma-immunoglobulins. Thus it is suspected that complex immunodysregulation in combination with immunosuppressive therapy is responsible for the high rate of oral and periodontal lesions in patients with systemic lupus erythematosus.

Invasive aspergillosis in systemic lupus erythematosus

Invasive aspergillosis is seldomly described in systemic lupus erythematosus. We present two cases of aspergillosis and review 21 cases reported between 1957 and 1994. The typical clinical presentation is fever and cough in a hospitalized SLE patient previously treated with corticosteroids, immunosuppressors, and broad-spectrum antibiotics. Unlike aspergillosis in other conditions, granulocytopenia is uncommon. Chest radiographs show diffuse or patchy infiltration of lung fields. Diagnosis was suspected premortem in 2 patients. Aspergillus fumigatus was identified or isolated in sputum or parenchimal tissues in the majority of cases. Twenty-two patients died (95%). The finding of hyphae in the sputum of a systemic lupus erythematosus patient with a suggestive clinical picture should lead to bronchoscopy, bronchoalveolar lavage, and lung biopsy. Proof of diagnosis will come from the demonstration of hyphae in tissues and isolation of aspergillus from tissue cultures. Long-term therapy with amphotericin B alone or in combination with fluorocytosine or itraconazole may help improve survival.

Pneumocystis carinii pneumonia in patients with systemic lupus erythematosus

At the University Hospital, Kuala Lumpur, Malaysia, nine patients with systemic lupus erythematosus (SLE) were treated for Pneumocystis carinii pneumonia (PCP) between January 1987 and December 1988. When they developed PCP all the patients' SLE disease course was active and eight of them were on prednisolone. Four of these eight patients were also receiving cyclophosphamide. Patients who were on more intensive immunosuppressive therapy were found to develop more severe PCP. All the patients except one were treated with high-dose cotrimoxazole. Four patients responded to antipneumocystis treatment and survived, while PCP was responsible for the death of the five non-survivors.

Staphylococcal infections in childhood dermatomyositis--association with the development of calcinosis, raised IgE concentrations and granulocyte chemotactic defect

There is a high incidence of staphylococcal infection in children with dermatomyositis, which is limited to those children who either already have or subsequently develop calcinosis. Of 15 children followed up for 3-10 years after diagnosis, all nine who developed calcinosis had infections with Staphylococcus aureus compared with none of six without calcinosis. Of these nine, the occurrence of staphylococcal infections before calcinosis was observed in four, suggested by history in two, and unclear in three children. Granulocyte chemotaxis to Staphylococcus aureus was more severely depressed in those children with calcinosis, whereas those without calcinosis did not differ significantly from controls. The chemotactic defect was due to a serum factor (patients' serum depressed control chemotaxis and control serum corrected the patients' chemotaxis). The nine children with calcinosis also had significantly higher serum IgE concentrations than non-atopic age matched controls; the six without calcinosis did not differ from controls. The increased IgE concentrations appeared to develop after staphylococcal infection and before calcinosis. Two of five patients with calcinosis had increased antistaphylococcal IgE antibodies; neither of the two patients without calcinosis had such increased antibodies. This suggests preceding immunological differences in patients with dermatomyositis who do and do not subsequently develop calcinosis, either increasing susceptibility to Staphylococcus aureus infection or potentially resulting from such infections.

Defective phagocytosis, decreased tumour necrosis factor-alpha production, and lymphocyte hyporesponsiveness predispose patients with systemic lupus erythematosus to infections

Twenty-three patients with systemic lupus erythematosus (SLE) were studied in order to understand the mechanism of increased susceptibility to infection in SLE patients. We found that phagocytosis by polymorphonuclear leucocytes (PMN) was significantly defective in untreated (24.2 +/- 3.1%) and immunosuppressant-treated SLE patients (30.0 +/- 3.6%) compared with normals (47.9 +/- 0.6%), while the generation of superoxide anion radicals was normal. The defective phagocytosis in SLE could be increased by human recombinant tumour necrosis factor alpha (TNF-alpha). However, the percentages of phagocytosis in SLE before and after TNF-alpha stimulation were 56.6% and 60.7% of the normal values. This indicates that certain populations of PMN in SLE are not only defective as regards phagocytosis but also unresponsive to TNF-alpha stimulation. In an ELISA, TNF-alpha production by phorbol myristate acetate (PMA)-stimulated mononuclear cells from SLE patients was significantly decreased (181.4 +/- 22.7 pg/ml vs. 533.0 +/- 81.9 pg/ml, p = 0.002). In addition, the percentage of phytohaemagglutinin (PHA)-stimulated mononuclear cells in S phase in the cell cycle was deficient in patients with SLE (17.2 +/- 1.8% vs. 29.7 +/- 2.9%, p less than 0.001). These results lead us to propose that defective PMN in spontaneous and TNF-alpha-induced phagocytosis, decreased production of TNF-alpha, and lymphocyte hyporesponsiveness predispose patients with SLE to infections.

Identification of a protein in sera of normal humans that inhibits fibroblast chemotactic and random migration in vitro

Normal human serum contains a 230,000 Mr protein that inhibits fibroblast chemotactic and random migration. This serum inhibitor of fibroblast migration (SIFM) is a heat-stable, trypsin-sensitive protein with a pI of 4.8 that reversibly inhibits the random and chemotactic migration of fibroblasts in vitro. Although SIFM effectively inhibits the chemotaxis of fibroblasts to interstitial collagens, fibronectin, lymphocyte-derived chemotactic factor for fibroblasts, and serum-derived chemotactic factor, it does not alter the chemotactic migration of human peripheral blood neutrophils or monocytes, and does not act as a cytotoxin to human dermal fibroblasts. The SIFM appears to act through a cell-directed mechanism to alter the fibroblast's ability to migrate. Serum inhibitor of fibroblast migration may function in vivo to modulate fibroblast migration under physiologic and pathologic conditions.

Coexistent systemic lupus erythematosus and tophaceous gout

Only seven patients with coexistent gout and systemic lupus erythematosus have been reported in the English-language literature. We describe an eighth case, which is the first, to our knowledge, in the dermatologic literature. The patient met four of the eleven new American Rheumatism Association criteria for the diagnosis of systemic lupus erythematosus, and clinical, laboratory, roentgenographic, and histologic assessments confirmed the diagnosis of gout.

Salmonella bacteremia in systemic lupus erythematosus. Eight-year experience at a municipal hospital

Non-endemic Salmonella bacteremia tends to occur in patients with chronic disease. We reviewed all cases of Salmonella infection documented in adults at Bellevue Hospital during the years 1975-1982. Unexpectedly, the most frequent underlying disease found among bacteremic patients was systemic lupus erythematosus (SLE). Patients with SLE accounted for 6 of 30 Salmonella bacteremias as compared with 13 of 2,388 non-Salmonella gram-negative bacteremias. Salmonella was the single most frequent gram-negative isolate from the blood of SLE patients. All lupus patients with Salmonella infection were bacteremic. In contrast, isolates from blood represented only 23% of all Salmonella infections documented in the non-lupus population. Presentation was characterized by fever (greater than 103 degrees F) and abdominal pain. Four of the 6 patients were hypocomplementemic. All were receiving immunosuppressive therapy. We conclude that SLE patients in a municipal hospital setting are at increased risk for Salmonella sepsis. This should be considered when empiric antibiotic therapy is initiated.

Acute necrotizing ulcerative gingivitis in a case of systemic lupus erythematosus

Presented is an unusually severe case of acute necrotizing ulcerative gingivitis (ANUG) in association with systemic lupus erythematosus (SLE), in which the patient was observed to slough a considerable amount of attached gingival tissues and eventually to lose a number of teeth and supporting bone. The usual limited and treatable nature of ANUG is reviewed, and attention is directed to the mechanisms by which SLE and therapeutic amounts of steroids can contribute to the increased severity of the oral disease.

Biologically active complement (C5)-derived peptides and their relevance to disease

In man and in most mammals, activation of the complement system via either the classical or the alternative pathway results in the generation of biologically active peptides. The most active peptides are C5a and C5a des Arg generated by cleavage of the alpha-chain of native C5. C5a is a potent anaphylatoxin and can induce human polymorphonuclear leukocytes to migrate in a directed fashion, to degranulate, to undergo a burst of oxidative metabolism and to aggregate. Upon generation C5a is converted in serum and plasma to C5a des Arg with loss of the noxious anaphylatoxin activity. C5a/C5a des Arg play important roles in host defenses against bacterial infections and possibly in the mediation of some pathologic lesions such as the leukocyte infiltration seen in the lungs during acute respiratory distress syndrome.

Histologic observations of coccoid forms suggestive of cell wall deficient bacteria in cutaneous and systemic lupus erythematosus

The cutaneous lesions of seven consecutive patients with cutaneous lupus erythematosus (LE), two patients with systemic LE, and a patient with both dermatomyositis and cutaneous LE, were studied bacteriologically and microscopically for the presence of bacteria. The study was prompted by the previous reports of variably acid-fast and non-acid-fast bacteria in other collagen diseases, and also by recent reports confirming the presence of cell wall deficient (CWD) bacteria (staphylococci, streptococci, and corynebacteria) within the hematologic elements of both "normal" and diseased individuals. Staphylococcus epidermis was isolated from four cases. Propionibacterium acnes from two cases, and Corynebacterium sp. from one case. Three cases were bacteriologically negative. Basophilic- and eosinophilic-stained coccoid forms, suggestive of CWD bacteria, were identified in the microscopic sections of all the cases, as were non-acid-fast coccoid forms. Definite acid-fast coccoid forms were observed in vivo in two cases of cutaneous LE. The complex bacteriology of LE is discussed, as well as the possibility that variably acid-fast CWD microbes might be the long sought-after etiologic agent or agents in the production of LE.

Effect of high-dose methylprednisolone infusion on polymorphonuclear leukocyte function in patients with systemic lupus erythematosus

We have studied the effect of high-dose (1 gm) methylprednisolone infusion on polymorphonuclear leukocyte (PMN) function in 11 patients with active systemic lupus erythematosus (SLE). The only alteration of polymorphonuclear leukocyte function produced consistently by methylprednisolone was decreased adherence to plastic surfaces when tested 2 hours after infusion. This steroid-induced abnormality, however, was transient. Cells obtained from patients 24 hours after a single dose of drug exhibited normal adhesiveness. These results indicate that single, large doses of methylprednisolone do not produce long-lasting abnormalities of PMN function in patients with lupus.