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Chastain DB, Spradlin M, Ahmad H, Henao-Martínez AF. Unintended Consequences: Risk of Opportunistic Infections Associated With Long-term Glucocorticoid Therapies in Adults. Clin Infect Dis 2024; 78:e37-e56. [PMID: 37669916 DOI: 10.1093/cid/ciad474] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Indexed: 09/07/2023] Open
Abstract
Glucocorticoids are widespread anti-inflammatory medications used in medical practice. The immunosuppressive effects of systemic glucocorticoids and increased susceptibility to infections are widely appreciated. However, the dose-dependent model frequently used may not accurately predict the risk of infection in all patients treated with long-term glucocorticoids. In this review, we examine the risks of opportunistic infections (OIs) in patients requiring glucocorticoid therapy by evaluating the influence of the glucocorticoid dose, duration, and potency, combined with biological and host clinical factors and concomitant immunosuppressive therapy. We propose strategies to prevent OIs, which involve screening, antimicrobial prophylaxis, and immunizations. While this review focuses on patients with autoimmune, inflammatory, or neoplastic diseases, the potential risks and preventative strategies are likely applicable to other populations. Clinicians should actively assess the benefit-harm ratios of systemic glucocorticoids and implement preventive efforts to decrease their associated infections complications.
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Affiliation(s)
- Daniel B Chastain
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, Georgia, USA
| | - Megan Spradlin
- Division of Medical Oncology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Hiba Ahmad
- Division of Medical Oncology, University of Colorado School of Medicine, Aurora, Colorado, USA
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Qian Y, Zhang Y, Huang J, Liu J, Chen G, Xia G, Wang C, Feng A, Chen Y, Chen J, Zeng Y, Nie X. Risk Factors for Pneumocystis jirovecii Pneumonia in Children With Systemic Lupus Erythematosus Exposed to Prolonged High-Dose Glucocorticoids. J Clin Rheumatol 2024:00124743-990000000-00189. [PMID: 38389131 DOI: 10.1097/rhu.0000000000002073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PJP) is a life-threatening opportunistic infection in immunocompromised children with systemic lupus erythematosus (SLE). Prophylaxis against PJP in high-risk children is crucial, but the risk factors for PJP in children with SLE are not adequately characterized. This study sought to identify the risk factors for PJP in long-term glucocorticoid-treated pediatric SLE patients. METHODS This study encompassed 71 treatment episodes involving 64 children with prolonged (≥4 weeks) high-dose (≥20 mg/d prednisone) steroid regimens. Fourteen treatment episodes involved the PJP, whereas others did not. Risk factors for PJP were assessed through Cox regression. The predictive value of these factors was evaluated using receiver operating characteristic curves. The incidence of PJP in different risk groups was compared using the Kaplan-Meier method. RESULTS The creatinine (hazard ratio, 1.009; 95% confidence interval [CI], 1.001-1.017; p = 0.021) and the lowest lymphocyte count (hazard ratio, 0.007; 95% CI, 0.000-0.373; p = 0.014) were independent risk factors for PJP in children with SLE. The receiver operating characteristic curve showed that using creatinine greater than 72.5 μmol/L and the lowest lymphocyte count less than 0.6 × 109/L as risk predictors for PJP resulted in an area under the curve value of 0.934 (95% CI, 0.870-0.997; p < 0.001). The study revealed a significant increase in PJP prevalence (p < 0.001) in children with elevated creatinine levels and low lymphocyte count. CONCLUSIONS Elevated levels of creatinine and decreased lymphocyte count are identified as distinct risk factors for PJP in children with SLE who receive prolonged high-dose steroid therapy.
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Affiliation(s)
| | | | | | - Jingjing Liu
- Department of Pediatrics, The 900th Hospital of the Joint Logistic Support Force, Fuzhou, China
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Xiong A, Luo W, Tang X, Cao Y, Xiang Q, Deng R, Shuai S. Risk factors for invasive fungal infections in patients with connective tissue disease: Systematic review and meta-analysis. Semin Arthritis Rheum 2023; 63:152257. [PMID: 37633041 DOI: 10.1016/j.semarthrit.2023.152257] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 07/25/2023] [Accepted: 08/15/2023] [Indexed: 08/28/2023]
Abstract
OBJECTIVE Invasive fungal infections (IFIs) are life-threatening opportunistic infections in patients with connective tissue disease CTD) that cause significant morbidity and mortality. We attempted to determine the potential risk factors associated with IFIs in CTD. METHODS We systematically searched PubMed, Embase, and the Cochrane Library databases for relevant articles published from the database inception to February 1, 2023. RESULTS Twenty-six studies were included in this systematic review and meta-analysis. Risk factors identified for IFIs were diabetes (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.00 to 2.64), pulmonary diseases (OR 3.43; 95% CI 2.49 to 4.73), interstitial lung disease (ILD; OR, 4.06; 95% CI, 2.22 to 7.41), renal disease (OR, 4.41; 95% CI, 1.84 to 10.59), glucocorticoid (GC) use (OR, 4.15; 95% CI, 2.74 to 6.28), especially moderate to high-dose GC, azathioprine (AZA) use (OR, 1.50; 95% CI, 1.12 to 2.01), calcineurin inhibitor (CNI) use (OR, 2.49; 95% CI, 1.59 to 3.91), mycophenolate mofetil (MMF) use (OR, 2.83; 95% CI, 1.59 to 5.03), cyclophosphamide (CYC) use (OR, 3.35; 95% CI, 2.47 to 4.54), biologics use (OR, 3.43; 95% CI, 2.36 to 4.98), and lymphopenia (OR, 4.26; 95% CI, 2.08 to 8.73). Hydroxychloroquine (HCQ) use reduced risk of IFIs (OR, 0.67; 95% CI, 0.54 to 0.84). Furthermore, 17 of the 26 studies only reported risk factors for Pneumocystis jiroveci pneumonia (PJP) in patients with CTD. Pulmonary disease; ILD; and the use of GC, CNIs, CYC, methotrexate (MTX), MMF and biologics, and lymphopenia increased the risk of PJP, whereas the use of HCQ reduced its risk. CONCLUSION Diabetes, pulmonary disease, ILD, renal disease, use of GC (especially at moderate to high dose) and immunosuppressive drugs, and lymphopenia were found to be associated with significant risk for IFIs (especially PJP) in patients with CTD. Furthermore, the use of HCQ may reduce the risk of IFIs in patients with CTD.
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Affiliation(s)
- Anji Xiong
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China; Inflammation and Immunology Key Laboratory of Nanchong, Nanchong, China.
| | - Wenxuan Luo
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Xiaoyu Tang
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Yuzi Cao
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Qilang Xiang
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Ruiting Deng
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Shiquan Shuai
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China; Inflammation and Immunology Key Laboratory of Nanchong, Nanchong, China
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Xue T, Kong X, Ma L. Trends in the Epidemiology of Pneumocystis Pneumonia in Immunocompromised Patients without HIV Infection. J Fungi (Basel) 2023; 9:812. [PMID: 37623583 PMCID: PMC10455156 DOI: 10.3390/jof9080812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/19/2023] [Accepted: 07/19/2023] [Indexed: 08/26/2023] Open
Abstract
The increasing morbidity and mortality of life-threatening Pneumocystis pneumonia (PCP) in immunocompromised people poses a global concern, prompting the World Health Organization to list it as one of the 19 priority invasive fungal diseases, calling for increased research and public health action. In response to this initiative, we provide this review on the epidemiology of PCP in non-HIV patients with various immunodeficient conditions, including the use of immunosuppressive agents, cancer therapies, solid organ and stem cell transplantation, autoimmune and inflammatory diseases, inherited or primary immunodeficiencies, and COVID-19. Special attention is given to the molecular epidemiology of PCP outbreaks in solid organ transplant recipients; the risk of PCP associated with the increasing use of immunodepleting monoclonal antibodies and a wide range of genetic defects causing primary immunodeficiency; the trend of concurrent infection of PCP in COVID-19; the prevalence of colonization; and the rising evidence supporting de novo infection rather than reactivation of latent infection in the pathogenesis of PCP. Additionally, we provide a concise discussion of the varying effects of different immunodeficient conditions on distinct components of the immune system. The objective of this review is to increase awareness and knowledge of PCP in non-HIV patients, thereby improving the early identification and treatment of patients susceptible to PCP.
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Affiliation(s)
- Ting Xue
- NHC Key Laboratory of Pneumoconiosis, Key Laboratory of Prophylaxis and Treatment and Basic Research of Respiratory Diseases of Shanxi Province, Shanxi Province Key Laboratory of Respiratory, Department of Respiratory and Critical Care Medicine, First Hospital of Shanxi Medical University, Taiyuan 030001, China
| | - Xiaomei Kong
- NHC Key Laboratory of Pneumoconiosis, Key Laboratory of Prophylaxis and Treatment and Basic Research of Respiratory Diseases of Shanxi Province, Shanxi Province Key Laboratory of Respiratory, Department of Respiratory and Critical Care Medicine, First Hospital of Shanxi Medical University, Taiyuan 030001, China
| | - Liang Ma
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD 20892, USA
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Chen R, Li X, Zheng D, Cao C, Su J. Co-Infection Talaromyces marneffei and Pneumocystis jirovecii in a Patient with Systemic Lupus Erythematosus. Infect Drug Resist 2023; 16:4913-4918. [PMID: 37534061 PMCID: PMC10390344 DOI: 10.2147/idr.s414763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/21/2023] [Indexed: 08/04/2023] Open
Abstract
Talaromyces marneffei (TM) and Pneumocystis jirovecii (PJ) infection are opportunistic infections that typically affect individuals with compromised immune systems, such as those with HIV or immunodeficiency. However, these infections are rarely seen in patients with systemic lupus erythematosus (SLE). We present a case study of a 52-year-old woman diagnosed with SLE who developed a co-infection of TM and PJ after receiving glucocorticoids, mycophenolate mofetil (MMF), and belimumab therapy. The patient's pneumonia improved following treatment with voriconazole, clarithromycin, and compound sulfamethoxazole. This case highlights the potential risk of serious opportunistic infections in SLE patients receiving a combination of glucocorticoids, MMF, and belimumab. Close monitoring of lymphocyte count, immunoglobulin levels, and chest computed tomography scans can aid in the early detection of infections. To the best of our knowledge, this is the first reported case of TM and PJ co-infection in an SLE patient.
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Affiliation(s)
- Rifeng Chen
- Department of Dermatology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, People’s Republic of China
| | - Xiuying Li
- Department of Dermatology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, People’s Republic of China
| | - Dongyan Zheng
- Department of Dermatology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, People’s Republic of China
| | - Cunwei Cao
- Department of Dermatology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, People’s Republic of China
| | - Jiaguang Su
- Department of Dermatology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, People’s Republic of China
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Clinical characteristics of and risk factors for Pneumocystis jirovecii pneumonia in anti-melanoma differentiation-associated gene 5 (Anti-MDA5) antibody-positive dermatomyositis patients: a single-center retrospective study. Clin Rheumatol 2023; 42:453-462. [PMID: 36301369 DOI: 10.1007/s10067-022-06403-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 09/04/2022] [Accepted: 10/04/2022] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Pneumocystis jirovecii pneumonia (PJP) is a serious opportunistic infection mainly diagnosed in patients with rheumatic conditions. However, PJP in anti-melanoma differentiation-associated gene 5-positive dermatomyositis (MDA5 + DM) patients remains poorly understood. We aimed to investigate the 6-month PJP risk in newly diagnosed MDA5 + DM patients. METHODS A retrospective observational study of 105 inpatients with newly diagnosed MDA5 + DM was conducted at Renji Hospital from January 2018 to November 2019. Demographic information, clinical characteristics, and treatment data were recorded. The primary outcome was PJP incidence within 6 months after a MDA5 + DM diagnosis. RESULTS The analysis included 105 patients, including 13 patients diagnosed with PJP during the observation period. The median time from the MDA5 + DM diagnosis to PJP was 89 ± 38 days. Compared with the PJP - patients, the PJP + patients had a significantly greater risk of mortality (69.2% vs. 13.0% P < 0.001). Regarding the baseline comorbidities, hypertension (P = 0.013) and cancer (P = 0.02) were more common in the PJP + group. Additionally, a larger proportion of the PJP + patients received prolonged high-dose steroid therapy (≥ 60 mg/day and ≥ 1 month) (P = 0.022) and double or triple immunosuppressant therapy (P = 0.013). The multivariate analysis showed that PJP was independently associated with lymphopenia (ALC < 500 cells/µl) (OR: 5.434, 95% CI: 2.074-55.155; P = 0.012) and the combined use of cyclophosphamide (CTX) and tacrolimus (TAC) (OR: 10.695, 95% CI: 1.440-20.508; P = 0.005). CONCLUSION There was a high incidence and mortality in the MDA5 + DM patients with PJP, with patients on combined immunosuppressive treatments, particularly CTX and TAC, being at a higher risk. Prolonged high-dose steroid therapy (≥ 60 mg/day and ≥ 1 month) was another risk factor for PJP. Key Points • There was a high incidence and mortality in the MDA5 + DM patients with PJP. • Most PJP cases occurred within 3 months after the MDA5 + DM diagnosis. • The 6-month infection risk of PJP increased with the administration of multiagent immunosuppression, especially the combination of CTX and TAC. • Prolonged high-dose steroid therapy (≥ 60 mg/day and ≥ 1 month) was another risk factor for PJP.
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Wang H, Shui L, Chen Y. Combine use of glucocorticoid with other immunosuppressants is a risk factor for Pneumocystis jirovecii pneumonia in autoimmune inflammatory disease patients: a meta-analysis. Clin Rheumatol 2023; 42:269-276. [PMID: 36149536 DOI: 10.1007/s10067-022-06381-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 08/16/2022] [Accepted: 09/16/2022] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To determine whether the combined use of glucocorticoid with other immunosuppressants increased the risk of Pneumocystis jirovecii pneumonia (PCP) in autoimmune inflammatory disease (AIID) patients. METHODS The data were collected from the PubMed, Cochrane Library, and Web of Science databases. We excluded HIV-infected patients and those < 16 years of age, and included patients who combined use of glucocorticoid with other immunosuppressants or used glucocorticoid alone. The number of patients who were affected by PCP after therapy as the primary outcome and the number of patients with fatal outcomes, which included death, endotracheal tube intubation, PO2 < 60 mmHg, and other serious clinical symptoms due to PCP, as the secondary outcome. Odds ratios with 95% confidence intervals and variance tests were used to analyze the data. RESULTS The outcomes showed that the combined use of glucocorticoid with other immunosuppressants increased the risk of PCP in AIID patients (odds ratio = 2.85, 95% confidence intervals 1.75 to 4.64, I2 = 0%, P < 0.0001), which may be a consequence of the drug regimen reducing the lymphocyte count. Furthermore, the prognosis of patients receiving this drug regimen was poorer than with glucocorticoid alone (odds ratio = 2.31, 95% confidence intervals 1.02 to 5.23, I2 = 0%, P = 0.04). CONCLUSION The combined use of glucocorticoid with other immunosuppressants increased the risk of PCP in AIID patients and resulted in poorer prognoses. It is therefore clear that appropriate prophylaxis was vital in AIID patients to minimize the risk of PCP. Key Points • We demonstrated that the combined use of glucocorticoid with other immunosuppressants increased the risk of PCP in AIID patients and resulted in poorer prognoses. • As there are no standard prophylactic guidelines, we wish this work will be evidence to guide clinical prophylaxis.
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Affiliation(s)
- Huyu Wang
- Department of Chongqing Medical University, Chongqing, 400016, China
| | - Lili Shui
- Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Yajuan Chen
- Department of Chongqing Medical University, Chongqing, 400016, China. .,Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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Fragoulis GE, Nikiphorou E, Dey M, Zhao SS, Courvoisier DS, Arnaud L, Atzeni F, Behrens GM, Bijlsma JW, Böhm P, Constantinou CA, Garcia-Diaz S, Kapetanovic MC, Lauper K, Luís M, Morel J, Nagy G, Polverino E, van Rompay J, Sebastiani M, Strangfeld A, de Thurah A, Galloway J, Hyrich KL. 2022 EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in adults with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis 2022; 82:742-753. [PMID: 36328476 DOI: 10.1136/ard-2022-223335] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022]
Abstract
ObjectivesTo develop EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in patients with autoimmune inflammatory rheumatic diseases (AIIRD).MethodsAn international Task Force (TF) (22 members/15 countries) formulated recommendations, supported by systematic literature review findings. Level of evidence and grade of recommendation were assigned for each recommendation. Level of agreement was provided anonymously by each TF member.ResultsFour overarching principles (OAP) and eight recommendations were developed. The OAPs highlight the need for infections to be discussed with patients and with other medical specialties, in accordance with national regulations. In addition to biologic/targeted synthetic disease-modifying antirheumatic drugs (DMARDs) for which screening for latent tuberculosis (TB) should be performed, screening could be considered also before conventional synthetic DMARDs, glucocorticoids and immunosuppressants. Interferon gamma release assay should be preferred over tuberculin skin test, where available. Hepatitis B (HBV) antiviral treatment should be guided by HBV status defined prior to starting antirheumatic drugs. All patients positive for hepatitis-C-RNA should be referred for antiviral treatment. Also, patients who are non-immune to varicella zoster virus should be informed about the availability of postexposure prophylaxis should they have contact with this pathogen. Prophylaxis againstPneumocystis jiroveciiseems to be beneficial in patients treated with daily doses >15–30 mg of prednisolone or equivalent for >2–4 weeks.ConclusionsThese recommendations provide guidance on the screening and prevention of chronic and opportunistic infections. Their adoption in clinical practice is recommended to standardise and optimise care to reduce the burden of opportunistic infections in people living with AIIRD.
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Affiliation(s)
- George E Fragoulis
- Joint Academic Rheumatology Program, First Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, King's College London, London, UK
- Rheumatology Department, King's College London, London, UK
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Rheumatology Department, Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Sizheng Steven Zhao
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Science, The University of Manchester, Manchester, UK
| | | | - Laurent Arnaud
- Department of Rheumatology, National Reference Center for Autoimmune Diseases (RESO), University Hospitals Strasbourg, Strasbourg, France
| | - Fabiola Atzeni
- Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, Messina, Italy
| | - Georg Mn Behrens
- Department for Rheumatology and Immunology, Hannover Medical School, Hannover, Germany
| | - Johannes Wj Bijlsma
- Dept of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Peter Böhm
- Forschungspartner, German League against rheumatism, Bonn, Germany
| | | | - Silvia Garcia-Diaz
- Rheumatology Department, Complex Hospitalari Moises Broggi, Barcelona, Spain
| | | | - Kim Lauper
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Science, The University of Manchester, Manchester, UK
- Division of Rheumatology, University of Geneva, Geneva, Switzerland
| | - Mariana Luís
- Rheumatology, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Jacques Morel
- Department of Rheumatology, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - György Nagy
- Department of Rheumatology and Clinical Immunology, Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Department of Genetics, Cell- and Immunobiology, Semmelweis University, Budapest, Hungary
| | - Eva Polverino
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Ciber de Enfermedades Respiratorias CIBERES, Barcelona, Spain
| | - Jef van Rompay
- Belgium Patient Partner Program, EULAR People with Arthritis/Rheumatism across Europe (PARE), Antwerpen, Belgium
| | - Marco Sebastiani
- Rheumatology Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Anja Strangfeld
- Epidemiology and Health Services Research, German Rheumatism Research Centre (DRFZ) Berlin and Charite University Medicine, Berlin, Germany
| | - Annette de Thurah
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - James Galloway
- Centre for Rheumatic Diseases, King's College London, London, UK
- Rheumatology Department, King's College London, London, UK
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Science, The University of Manchester, Manchester, UK
- National Institute of Health Research Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester NHS Foundation Trust, Manchester, UK
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Jinno S, Akashi K, Onishi A, Nose Y, Yamashita M, Saegusa J. Comparative effectiveness of trimethoprim-sulfamethoxazole versus atovaquone for the prophylaxis of pneumocystis pneumonia in patients with connective tissue diseases receiving prolonged high-dose glucocorticoids. Rheumatol Int 2021; 42:1403-1409. [PMID: 34263352 DOI: 10.1007/s00296-021-04945-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 07/07/2021] [Indexed: 11/30/2022]
Abstract
We compared the prophylactic effect of trimethoprim-sulfamethoxazole (TMP-SMX) with atovaquone for pneumocystis pneumonia (PCP) in patients with connective tissue diseases (CTDs) receiving high-dose glucocorticoids. Patients with CTDs aged ≥ 18 years who were treated with a prolonged course (≥ 4 weeks) of glucocorticoids (≥ 20 mg/day prednisone) in a Japanese tertiary center between 2013 and 2017 were included. The patients were categorized into two groups: TMP-SMX and atovaquone group. Adjusted cumulative incidence of PCP was compared between the two groups after propensity score weighting for differences in confounding factors. A total of 480 patients with a prolonged high-dose glucocorticoid treatment were identified. Out of 383 patients with TMP-SMX prophylaxis, 102 (26.8%) patients experienced adverse events leading to discontinuation within 4 weeks of initiation, while no patient in the atovaquone discontinued the therapy. Two hundred eighty-one patients received TMP-SMX, while 107 received atovaquone for PCP prophylaxis. During a total of 397.0 person-years, 7 PCP cases (2 in the TMP-SMX, 5 in the atovaquone) occurred with a mortality rate of 54.5%. After adjusting for differences in baseline characteristics, the adjusted cumulative incidence of PCP was similar between the two group (HR 0.97, 95% CI 0.19-5.09, p = 0.97). Prophylactic effects for PCP in CTDs patients receiving prolonged high-dose glucocorticoids were similar between TMP-SMX and atovaquone. Atovaquone was well-tolerated with no side effects.
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Affiliation(s)
- Sadao Jinno
- Department of Rheumatology and Clinical Immunology, University Graduate School of Medicine, 7-5-2 Kusunoki-chou, Kobe, Hyogo, 650-0017, Japan.
| | - Kengo Akashi
- Department of Rheumatology and Clinical Immunology, University Graduate School of Medicine, 7-5-2 Kusunoki-chou, Kobe, Hyogo, 650-0017, Japan
| | - Akira Onishi
- Department of Advanced Medicine for Rheumatic Diseases, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoko Nose
- Department of Rheumatology and Clinical Immunology, University Graduate School of Medicine, 7-5-2 Kusunoki-chou, Kobe, Hyogo, 650-0017, Japan
| | - Mai Yamashita
- Department of Rheumatology and Clinical Immunology, University Graduate School of Medicine, 7-5-2 Kusunoki-chou, Kobe, Hyogo, 650-0017, Japan
| | - Jun Saegusa
- Department of Rheumatology and Clinical Immunology, University Graduate School of Medicine, 7-5-2 Kusunoki-chou, Kobe, Hyogo, 650-0017, Japan
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Wang WH, Lai CC, Huang YF, Li TH, Tsao YP, Chen WS, Chang YS. Pneumocystis jirovecii pneumonia in systemic lupus erythematosus: a nationwide cohort study in Taiwan. Arthritis Care Res (Hoboken) 2021; 74:1444-1450. [PMID: 33645012 DOI: 10.1002/acr.24584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 01/18/2021] [Accepted: 02/23/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To evaluate PJP infection risk in patients with SLE in Taiwan. METHODS We identified 24,367 patients with SLE from the National Health Insurance research database between 1997 and 2012 and compared the PJP incidence rates (IRs) with those in 243,670 age- and sex-matched non-SLE controls. PJP risk in the patients was evaluated using a Cox multivariate proportional hazards model. RESULTS The patients exhibited a significantly higher PJP risk than the controls, with an IR of 2.63 per 10,000 person-years and IR ratio of 27.65 (95% CI 17.2-45.3, p < 0.001). Male sex (hazard ratio [HR] 2.42, p < 0.01), end-stage renal disease (ESRD; HR 1.74, p = 0.01), recent use of mycofenolate mofetil (MMF; HR 4.43, P < 0.001), intravenous steroid pulse therapy (HR 108.73, p < 0.001), and average oral dose of >7.5 mg/day prednisolone or equivalent (HR 4.83, p < 0.001) were associated with PJP in SLE, whereas hydroxychloroquine use reduced its risk (HR 0.51, p = 0.01). Of note, cyclophosphamide was not associated with PJP infection in the multivariate Cox proportional hazard model. CONCLUSIONS Patients with SLE have a considerably high PJP risk. Cyclophosphamide does not increase PJP risk. Male sex, ESRD, MMF use, intravenous steroid pulse therapy, oral prednisolone or equivalent (>7.5 mg/day) are risk factors for PJP, whereas hydroxychloroquine use reduces PJP risk.
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Affiliation(s)
- Wen-Hsiu Wang
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, Mackay Medical College, New Taipei City, Taiwan.,Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan
| | - Chien-Chih Lai
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yi-Fan Huang
- Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Taitung Mackay Memorial Hospital, Taitung, Taiwan
| | - Tzu-Hao Li
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Chiayi Branch, Taichung Veterans General Hospital, Taiwan
| | - Yen-Po Tsao
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Sheng Chen
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Sheng Chang
- Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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11
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Harada T, Kato R, Sueda Y, Funaki Y, Takata M, Okazaki R, Hasegawa Y, Yamasaki A. The efficacy and safety of reduced-dose sulfamethoxazole-trimethoprim for chemoprophylaxis of Pneumocystis pneumonia in patients with rheumatic diseases. Mod Rheumatol 2020; 31:629-635. [PMID: 32820678 DOI: 10.1080/14397595.2020.1812834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Pneumocystis pneumonia (PCP) is a life-threatening opportunistic infection. Sulfamethoxazole-trimethoprim (SMX/TMP) is the first-line drug for PCP prophylaxis. However, adverse events (AEs) force clinicians to alter or reduce the drug dosage. METHODS We retrospectively reviewed all patients with rheumatic diseases who received SMX/TMP for prophylaxis and glucocorticoid therapy between April 2004 and March 2018. The rates of AEs, SMX/TMP discontinuation, and incidence of PCP were analyzed. Patients were divided into the conventional group and the dose-reduction group. RESULTS One hundred forty-five patients and 75 patients were included in the conventional group and the dose-reduction group, respectively. Compared to the dose-reduction group, the conventional group had a significantly high frequency of AEs (10.7% vs. 24.1%; p = .017); however, the rate of discontinuing SMX/TMP was not significantly different (8.0% vs. 14.5%; p = .165). Thirteen conventional group patients required a reduced SMX/TMP dose because of AEs; no patient developed PCP. The conventional SMX/TMP dose and renal dysfunction were associated with AEs in multivariate analysis. CONCLUSION Patients who received a reduced SMX/TMP dose did not have PCP and had a lower frequency of AEs. A reduction in SMX/TMP for PCP prophylaxis is effective and safe in patients with rheumatic disease.
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Affiliation(s)
- Tomoya Harada
- Division of Respiratory Medicine and Rheumatology, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Ryohei Kato
- Division of Respiratory Medicine and Rheumatology, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Yuriko Sueda
- Division of Respiratory Medicine and Rheumatology, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Yoshihiro Funaki
- Division of Respiratory Medicine and Rheumatology, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Miki Takata
- Division of Respiratory Medicine and Rheumatology, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Ryota Okazaki
- Division of Respiratory Medicine and Rheumatology, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Yasuyuki Hasegawa
- Division of Rheumatology, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Akira Yamasaki
- Division of Respiratory Medicine and Rheumatology, Faculty of Medicine, Tottori University, Tottori, Japan
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12
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Verhaert M, Blockmans D, De Langhe E, Henckaerts L. Pneumocystis jirovecii pneumonia in patients treated for systemic autoimmune disorders: a retrospective analysis of patient characteristics and outcome. Scand J Rheumatol 2020; 49:345-352. [DOI: 10.1080/03009742.2020.1762921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- M Verhaert
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - D Blockmans
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - E De Langhe
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - L Henckaerts
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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13
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Lai CC, Sun YS, Lin FC, Yang CY, Tsai CY. Bronchoalveolar lavage fluid analysis and mortality risk in systemic lupus erythematosus patients with pneumonia and respiratory failure. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2020; 54:1048-1055. [PMID: 32675043 DOI: 10.1016/j.jmii.2020.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/23/2020] [Accepted: 07/06/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Our aim was to characterize etiologic diagnoses obtained from bronchoalveolar lavage fluid (BALF) and blood specimens, and to identify risk factors for mortality in systemic lupus erythematosus (SLE) patients with pneumonia and respiratory failure. METHODS We conducted a retrospective analysis of SLE patients with pneumonia and respiratory failure. Clinical characteristics, laboratory profiles, and microbiology in BALF and blood samples were evaluated. We performed univariable analyses to identify mortality risk factors. RESULTS All 24 patients (F:M = 21:3, median age 46.5 years; disease duration 11 years) received mechanical ventilation (median duration: 11 days). Pathogens identified in BALF included Pneumocystis jiroveci (12 patients [50%]), cytomegalovirus (CMV, 7 patients [29.2%]), and bacteria (11 patients [45.8%]). Thirteen patients (54.2%) yielded pathogens in blood (CMV in 8 patients [33.3%] and Escherichia coli in 5 patients [20.8%]). Eight developed septic shock, and 9 died within 30 days. Univariable analysis identified thrombocytopenia (odds ratio [OR]: 8.0, 95% confidence interval [CI]: 1.23-52.25), bacteremia within 30 days before or after endotracheal intubation (OR: 8.0, 95% CI: 1.23-52.5), and P. jiroveci pneumonia (PJP, OR: 7.0, 95% CI: 1.04-46.95) as risk factors for 30-day mortality. Kaplan-Meier analysis confirmed an increased risk of 30-day mortality with thrombocytopenia and bacteremia. CONCLUSION There are high prevalence rates of PJP and CMV infections as evidenced by BALF analyses in SLE patients with pneumonia and respiratory failure. BALF analysis can facilitate rescue therapy per pathogen. Thrombocytopenia, bacteremia, and PJP in SLE patients can increase their 30-day mortality, so warrant early and aggressive treatments.
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Affiliation(s)
- Chien-Chih Lai
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taiwan; Faculty of Medicine, National Yang-Ming University, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taiwan
| | - Yi-Syuan Sun
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taiwan; Faculty of Medicine, National Yang-Ming University, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taiwan
| | - Fang-Chi Lin
- Department of Chest Medicine, Taipei Veterans General Hospital, Taiwan
| | - Chih-Yu Yang
- Institute of Clinical Medicine, National Yang-Ming University, Taiwan; Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taiwan; Center for Intelligent Drug Systems and Smart Bio-devices (IDS(2)B), Taiwan
| | - Chang-Youh Tsai
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taiwan; Faculty of Medicine, National Yang-Ming University, Taiwan.
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14
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Yuan Q, Xing X, Lu Z, Li X. Clinical characteristics and risk factors of infection in patients with systemic lupus erythematosus: A systematic review and meta-analysis of observational studies. Semin Arthritis Rheum 2020; 50:1022-1039. [PMID: 32911280 DOI: 10.1016/j.semarthrit.2020.06.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 06/02/2020] [Accepted: 06/08/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Infection is one of the major causes of morbidity and mortality in systemic lupus erythematosus (SLE) patients. We conducted a systematic review and meta-analysis to investigate the clinical characteristics and risk factors of infection in SLE by comparing demographic factors, laboratory data, clinical features, and therapeutic factors between infection and non-infection SLE patients. METHODS PubMed, Embase, and Cochrane databases were searched systematically without restricting the language or year (up to September 2019) by using MeSH terms and keywords pertaining to SLE and infection. Three independent reviewers selected all observational studies based on the established inclusion criteria. Odds ratio (OR) and standardized mean difference (SMD) along with 95% confidence intervals (CI) were used and the analyses were carried out by using a random/fixed-effects model. When necessary, different subgroup and sensitivity analyses were conducted. Study quality was assessed by the modified version (nine-star scoring system) of the Newcastle-Ottawa Scale (NOS) and publication bias was evaluated by funnel plots, and Egger's and Begg's tests. RESULTS In total, we included 39 studies (3709 infection SLE patients and 10526 non-infection SLE patients) based on the inclusion criteria. Compared with the SLE patients without infection, we found that infected SLE patients had a significantly higher incidence rate of the following: 1) lymphopenia (OR = 2.738 95%CI (1.017-7.376), P = 0.046, I2 = 81.4%), 2) thrombocytopenia (OR = 1.61 95%CI (1.4-1.85), P<0.001, I2 = 0%), 3) anemia (OR = 2.294 95%CI (1.402-3.755), P = 0.001, I2 = 83.0%), 4) hypoproteinemia (OR = 2.336 95%CI (1.408-3.876), P = 0.001, I2 = 84.2%), 5) C3 consumed (OR = 1.890 95%CI (1.190-3.002), P = 0.007, I2 = 77.4%), 6) diabetes mellitus (OR = 3.890 95%CI (2.450-6.160), P < 0.001, I2 = 0%), 7) elevated creatinine (OR = 1.954 95%CI (1.646-2.320), P < 0.001, I2 = 0.0%), 8) renal involvement (OR = 2.692 95%CI (2.000-3.623), P < 0.001, I2 = 76.0%), 9) serositis (OR = 3.877 95%CI (0.995-15.110), P = 0.051, I2 = 79.1%), and 10) use of steroid immunosuppressants (OR = 3.116 95%CI (1.959-4.957), P < 0.001, I2 = 77.9%). Furthermore, infected SLE patients had a significantly higher mean dose of prednisone (SMD = 2.088 95%CI (1.196-2.981), P < 0.001, I2 = 97.8%). In addition, SLE patients with infection showed a significantly lower incidence of antimalarial drug use (OR = 0.634 95%CI (0.451-0.892), P = 0.009, I2 = 56.0%). Infected SLE patients had a significantly higher level of 1) 24-h urinary protein (SMD = 0.560 95%CI (0.300-0.810), P < 0.001, I2 = 0%), 2) CRP (SMD = 0.437 95%CI (0.184-0.691), P = 0.001, I2 = 68.6%), and 3) SLE Collaborating Clinics damage index (SDI) (SMD = 0.451 95%CI (0.238-0.664), P < 0.001, I2 = 0.0%), along with a significantly lower level of albumin (SMD = -0.400 95%CI (-0.610--0.200), P < 0.001, I2 = 0.0%). After adjustment for false discovery rate (FDR), lymphopenia and serositis were no longer associated with the occurrence of infection; however, the remaining factors were still associated with infection in SLE. According to the nine-star scoring system of NOS, 71.79% of the studies were considered as high methodological quality (low risk of bias). No significant publication bias, except for renal involvement, was detected from funnel plots or Egger's and Begg's test, while this publication bias of renal involvement did not impact the pooled estimates. CONCLUSION We identified many factors including thrombocytopenia, anemia, hypoproteinemia, hypocomplementemia, hypoalbuminemia, higher level of CRP, higher SDI score, renal involvement and diabetes mellitus that were associated with infection in SLE patients. In addition, glucocorticoids (especially high-dose) and immunosuppressants (e.g. cyclophosphamide) rendered SLE patients more susceptible to infection, while antimalarial drug administration (hydroxychloroquine) was a protective factor against infection in SLE patients. SLE patients with the above clinical characteristics and risk factors might be at high risk from infection, which might contribute to the early identification of infection in SLE patients for better prognosis.
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Affiliation(s)
- Qihang Yuan
- Department of Immunology, College of Basic Medical Science, Dalian Medical University, Dalian, PR China
| | - Xue Xing
- Department of Immunology, College of Basic Medical Science, Dalian Medical University, Dalian, PR China
| | - Zhimin Lu
- Department of Immunology, College of Basic Medical Science, Dalian Medical University, Dalian, PR China; Department of Rheumatology, Affiliated Hospital of Nantong University, Nantong, PR China.
| | - Xia Li
- Department of Immunology, College of Basic Medical Science, Dalian Medical University, Dalian, PR China.
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15
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Ghembaza A, Vautier M, Cacoub P, Pourcher V, Saadoun D. Risk Factors and Prevention of Pneumocystis jirovecii Pneumonia in Patients With Autoimmune and Inflammatory Diseases. Chest 2020; 158:2323-2332. [PMID: 32502592 DOI: 10.1016/j.chest.2020.05.558] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 05/21/2020] [Accepted: 05/28/2020] [Indexed: 02/02/2023] Open
Abstract
Patients with autoimmune and/or inflammatory diseases (AIIDs) are prone to serious infectious complications such as Pneumocystis jirovecii pneumonia (PJP). In non-HIV patients, the prognosis is poorer, and diagnostic tests are of lower sensitivity. Given the low incidence of PJP in AIIDs, with the exception of granulomatosis with polyangiitis, and the non-negligible side effects of chemoprophylaxis, routine prescription of primary prophylaxis is still debated. Absolute peripheral lymphopenia, high doses of corticosteroids, combination with other immunosuppressive agents, and concomitant lung disease are strong predictors for the development of PJP and thus should warrant primary prophylaxis. Trimethoprim-sulfamethoxazole is considered first-line therapy and is the most extensively used drug for PJP prophylaxis. Nevertheless, it may expose patients to side effects. Effective alternative drugs such as atovaquone or aerosolized pentamidine could be used when trimethoprim-sulfamethoxazole is not tolerated or contraindicated. No standard guidelines are available to guide PJP prophylaxis in patients with AIIDs. This review covers the epidemiology, risk factors, and prevention of pneumocystis in the context of AIIDs.
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Affiliation(s)
- Amine Ghembaza
- Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; Centre national de références Maladies Autoimmunes systémiques rares et Centre national de références Maladies Autoinflammatoires et amylose inflammatoire; Immunology-Immunopathology-Immunotherapy (I3), Sorbonne Universités, UPMC Université Paris 6, INSERM, UMR S 959, Paris, France
| | - Mathieu Vautier
- Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; Centre national de références Maladies Autoimmunes systémiques rares et Centre national de références Maladies Autoinflammatoires et amylose inflammatoire; Immunology-Immunopathology-Immunotherapy (I3), Sorbonne Universités, UPMC Université Paris 6, INSERM, UMR S 959, Paris, France
| | - Patrice Cacoub
- Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; Centre national de références Maladies Autoimmunes systémiques rares et Centre national de références Maladies Autoinflammatoires et amylose inflammatoire; Immunology-Immunopathology-Immunotherapy (I3), Sorbonne Universités, UPMC Université Paris 6, INSERM, UMR S 959, Paris, France
| | - Valérie Pourcher
- Service des maladies infectieuses et tropicales, hôpital Pitié-Salpêtrière, AP-HP, Paris, France; INSERM UMR-S 1136, Pierre Louis Institute of Epidemiology and Public Health, Sorbonne Université, Paris, France
| | - David Saadoun
- Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; Centre national de références Maladies Autoimmunes systémiques rares et Centre national de références Maladies Autoinflammatoires et amylose inflammatoire; Immunology-Immunopathology-Immunotherapy (I3), Sorbonne Universités, UPMC Université Paris 6, INSERM, UMR S 959, Paris, France.
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16
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Bavaro DF, Fiordelisi D, Angarano G, Monno L, Saracino A. Targeted therapies for autoimmune/idiopathic nonmalignant diseases: risk and management of opportunistic infections. Expert Opin Drug Saf 2020; 19:817-842. [PMID: 32394759 DOI: 10.1080/14740338.2020.1767585] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION The management of patients affected by autoimmune/idiopathic diseases has been revolutionized by the development of targeted therapies (TT). However, the use of TT is complicated by several adverse events, like opportunistic infections (OIs). The potential of TT to predispose to OIs mainly depends on the site of action; nevertheless, such associations are far from being deterministic, because many factors could increase the infection risk. AREAS COVERED The impact on the infective risk of different TT used for autoimmune/idiopathic diseases is far from being completely understood. Indeed, many post-marketing reports documented severe or unexpected infections in patients treated with TT that did not emerge during registrative trials. In this review, the authors attempt to provide an easy and practical update about the 'infectious' safety of TT and examine the management strategies of OIs and other infections more frequently observed in the course of treatment with TT. EXPERT OPINION The authors suggest to precisely schedule the clinical management of these subjects, both to prevent and eventually treat promptly the TT-related infectious complications. A coordinated approach should be implemented from different medical specialties to improve the overall understanding of safety of TT and, in general, the management of opportunistic infections in immune-compromised hosts.
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Affiliation(s)
- Davide Fiore Bavaro
- Department of Biomedical Sciences and Human Oncology, Clinic of Infectious Diseases, University of Bari "Aldo Moro" , Bari, Italy
| | - Deborah Fiordelisi
- Department of Biomedical Sciences and Human Oncology, Clinic of Infectious Diseases, University of Bari "Aldo Moro" , Bari, Italy
| | - Gioacchino Angarano
- Department of Biomedical Sciences and Human Oncology, Clinic of Infectious Diseases, University of Bari "Aldo Moro" , Bari, Italy
| | - Laura Monno
- Department of Biomedical Sciences and Human Oncology, Clinic of Infectious Diseases, University of Bari "Aldo Moro" , Bari, Italy
| | - Annalisa Saracino
- Department of Biomedical Sciences and Human Oncology, Clinic of Infectious Diseases, University of Bari "Aldo Moro" , Bari, Italy
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Vela Casasempere P, Ruiz Torregrosa P, García Sevila R. Pneumocystis jirovecii in immunocompromised patients with rheumatic diseases. ACTA ACUST UNITED AC 2020; 17:290-296. [PMID: 32466869 DOI: 10.1016/j.reuma.2020.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 12/30/2019] [Accepted: 02/28/2020] [Indexed: 12/14/2022]
Abstract
Infections, including opportunistic infections, are a major and frequent cause of morbidity and mortality in patients with systemic autoimmune and rheumatic diseases. Pneumocystis jirovecii pneumonia, classically considered to be typical of HIV patients, transplanted patients or patients treated with oncological chemotherapy, is appearing increasingly frequently in these patients. Therefore, rheumatologists should know its mechanism of production, clinical manifestations, treatment and prophylaxis, all of which are addressed in this review.
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Affiliation(s)
- Paloma Vela Casasempere
- Sección de Reumatología. Hospital General Universitario de Alicante. ISABIAL, Alicante, España; Universidad Miguel Hernández, Alicante, España.
| | | | - Raquel García Sevila
- Servicio de Neumología. Hospital General Universitario de Alicante, Alicante, España
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Qin L, Qiu Z, Hsieh E, Geng T, Zhao J, Zeng X, Wan L, Xie J, Ramendra R, Routy JP, Li T. Association between lymphocyte subsets and cytomegalovirus infection status among patients with systemic lupus erythematosus: A pilot study. Medicine (Baltimore) 2019; 98:e16997. [PMID: 31574798 PMCID: PMC6775378 DOI: 10.1097/md.0000000000016997] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/26/2019] [Accepted: 08/06/2019] [Indexed: 11/04/2022] Open
Abstract
This study aimed to determine the association between different lymphocyte subsets and cytomegalovirus (CMV) infection status in patients with systemic lupus erythematosus (SLE). We performed a retrospective study among SLE patients with CMV infection and collected patient socio-demographic and clinical characteristics, as well as their recorded circulating lymphocyte subsets. Univariate and multivariable logistic regression analyses examined the relationship between CMV infection status and lymphocyte subset counts. We included 125 hospitalized patients with SLE, consisting of 88 with documented CMV infection and 37 without any evidence of CMV or other infections. Among the 88 CMV-infected patients, 65 (73.8%) patients developed CMV disease and 23 (26.2%) presented as CMV viremia. Compared to uninfected patients (1520 ± 101 cells/μL), lymphocytes remained stable among those with CMV viremia (1305 ± 272 cells/μL, P = .995). However, compared to their uninfected counterparts, there was a marked decrease in lymphocytes among patients with CMV disease (680 ± 513 cells/μL, P < .001). Analysis of lymphocyte subsets via flow cytometry showed that CD4+ T cell, CD8+ T cell, and natural killer cell counts were lower among those with CMV disease compared to those with CMV viremia and those without infection. Further, multivariable analysis showed that total lymphocyte (odds ratio [OR] 0.999, 95% confidence interval [CI] 0.998-1.000, P = .007) and CD4+ T cell counts (OR 0.99, 95% CI 0.992-0.998, P = .003) were negatively associated with CMV disease. Our findings support a potential inverse relationship between lymphopenia, specifically CD4+ T-cell lymphopenia, and CMV disease among hospitalized SLE patients.
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Affiliation(s)
- Ling Qin
- Department of Infectious Diseases, Peking Union Medical College Hospital
- Center for AIDS Research
| | - Zhifeng Qiu
- Department of Infectious Diseases, Peking Union Medical College Hospital
- Center for AIDS Research
- Clinical Immunology Center, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Evelyn Hsieh
- Department of Infectious Diseases, Peking Union Medical College Hospital
- Section of Rheumatology, Allergy & Immunology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Taoran Geng
- Department of Infectious Diseases, Peking Union Medical College Hospital
- Center for AIDS Research
| | | | | | - Lu Wan
- Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jing Xie
- Department of Infectious Diseases, Peking Union Medical College Hospital
- Center for AIDS Research
- Clinical Immunology Center, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Rayoun Ramendra
- Department of Microbiology and Immunology, McGill University
| | - Jean Pierre Routy
- Chronic Viral Illnesses Service and Division of Hematology, McGill University Health Centre, Montreal, QC, Canada
| | - Taisheng Li
- Department of Infectious Diseases, Peking Union Medical College Hospital
- Center for AIDS Research
- Clinical Immunology Center, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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19
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Wang ZG, Liu XM, Wang Q, Chen NF, Tong SQ. A retrospective study of patients with systemic lupus erythematosus combined with Pneumocystis jiroveci pneumonia treated with caspofungin and trimethoprim/sulfamethoxazole. Medicine (Baltimore) 2019; 98:e15997. [PMID: 31169741 PMCID: PMC6571266 DOI: 10.1097/md.0000000000015997] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Systemic lupus erythematosus (SLE) complicated with Pneumocystis jiroveci pneumonia (PCP) is a clinical complex with unsatisfying treatment efficacy and poor prognosis which is difficult to be diagnosed at early stage. The present study aimed to investigate the clinical features of SLE with PCP, recognize the early onset indicating factors, and evaluate the treatment efficacy of combined caspofungin and trimethoprim/sulfamethoxazole (coSMZ).We reviewed data of 9 patients admitted with SLE-PCP and treated with caspofungin combined with coSMZ at Tangshan Gongren Hospital from January 2013 to December 2017. Patients' clinical manifestation and laboratory data [leucocyte, lymphocyte, cluster of differentiation 4 (CD4)T cell, lactate dehydrogenase (LDH), blood gas, etc] were compared before and after treatments. And the early onset factors of SLE-PCP, treatment efficacy of combined caspofungin and CoSMZ were analyzed.Among these 9 patients, 8 patients suffered renal impairment, and all of them had been taking prednisone in the past 3 months at an average dose of 29.4 ± 13.6 mg/day. In addition, they had taken at least one kind of immunosuppressants. Laboratory data (leucocyte, lymphocyte, CD4T cell, PaO2, LDH) were remarkably abnormal at hospital admission, but they were improved significantly after 2 weeks of treatment, which is also statistically significant (P < .05), except that leukocyte had no significance change to the value at admission (P = .973). In addition, none of the studied patients died.The results of the study indicated that long-term use of glucocorticoids and immunosuppressants, low CD4T cell count, and renal impairment are the early-onset factors for SLE-PCP, caspofungin, when combined with CoSMZ, it could be a promising and effective strategy to treat SLE with PCP.
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Affiliation(s)
| | - Xue-Ming Liu
- Department of Nursing, Tangshan Gongren Hospital of Hebei Medical University, Tangshan, China
| | - Qian Wang
- Department of Rheumatology and Immunology
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Wu L, Wang X, Chen F, Lv X, Sun W, Guo Y, Hou H, Ji H, Wei W, Gong L. T cell subsets and immunoglobulin G levels are associated with the infection status of systemic lupus erythematosus patients. ACTA ACUST UNITED AC 2017; 51:e4547. [PMID: 29267496 PMCID: PMC5731325 DOI: 10.1590/1414-431x20154547] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 04/23/2015] [Indexed: 11/23/2022]
Abstract
Systemic lupus erythematosus (SLE) is a chronic, autoimmune disorder that affects nearly all organs and tissues. As knowledge about the mechanism of SLE has increased, some immunosuppressive agents have become routinely used in clinical care, and infections have become one of the direct causes of mortality in SLE patients. To identify the risk factors indicative of infection in SLE patients, a case control study of our hospital's medical records between 2011 and 2013 was performed. We reviewed the records of 117 SLE patients with infection and 61 SLE patients without infection. Changes in the levels of T cell subsets, immunoglobulin G (IgG), complement C3, complement C4, globulin, and anti-double-stranded DNA (anti-ds-DNA) were detected. CD4+ and CD4+/CD8+ T cell levels were significantly lower and CD8+ T cell levels were significantly greater in SLE patients with infection than in SLE patients without infection. Additionally, the concentrations of IgG in SLE patients with infection were significantly lower than those in SLE patients without infection. However, complement C3, complement C4, globulin, and anti-ds-DNA levels were not significantly different in SLE patients with and without infection. Therefore, clinical testing for T cell subsets and IgG is potentially useful for identifying the presence of infection in SLE patients and for distinguishing a lupus flare from an acute infection.
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Affiliation(s)
- Lifen Wu
- Department of Ultrasonography, Tianjin Medical University General Hospital, Tianjin, China
| | - Xinru Wang
- Department of Medical Clinical Laboratory, The General Hospital of People's Liberation Army Rocket Force, Beijing, China
| | - Fenghua Chen
- Department of Obstetrics and Gynecology, Reproductive Medical Centre, Peking University Third Hospital, Beijing, China
| | - Xing Lv
- Department of Rheumatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Wenwen Sun
- Department of Rheumatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Ying Guo
- Department of Rheumatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Hou Hou
- Department of Rheumatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Haiyan Ji
- Department of Rheumatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Wei Wei
- Department of Rheumatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Lu Gong
- Department of Rheumatology, Tianjin Medical University General Hospital, Tianjin, China
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Park JW, Curtis JR, Moon J, Song YW, Kim S, Lee EB. Prophylactic effect of trimethoprim-sulfamethoxazole for pneumocystis pneumonia in patients with rheumatic diseases exposed to prolonged high-dose glucocorticoids. Ann Rheum Dis 2017; 77:644-649. [PMID: 29092853 PMCID: PMC5909751 DOI: 10.1136/annrheumdis-2017-211796] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 10/01/2017] [Accepted: 10/22/2017] [Indexed: 12/25/2022]
Abstract
Objectives To investigate the efficacy and safety of trimethoprim/sulfamethoxazole (TMP-SMX) as primary prophylaxis for pneumocystis pneumonia (PCP) in patients with rheumatic diseases receiving high-dose steroids. Methods The study included 1522 treatment episodes with prolonged (≥4 weeks) high-dose (≥30 mg/day prednisone) steroids in 1092 patients over a 12-year period. Of these, 262 treatment episodes involved TMP-SMX (prophylaxis group) while other episodes involved no prophylaxis (control group). Differences in 1-year PCP incidence and its mortality between the two groups were estimated using Cox regression. To minimise baseline imbalance, propensity score matching was performed and efficacy outcome was mainly assessed in the postmatched population (n=235 in both groups). Results During a total of 1474.4 person-years, 30 PCP cases occurred with a mortality rate of 36.7%. One non-fatal case occurred in the prophylaxis group. TMP-SMX significantly reduced the 1-year PCP incidence (adjusted HR=0.07(95% CI 0.01 to 0.53)) and related mortality (adjusted HR=0.08 (95% CI 0.0006 to 0.71)) in the postmatched population. The result of the same analysis performed in the whole population was consistent with that of the primary analysis. Incidence rate of adverse drug reactions (ADR) related to TMP-SMX was 21.2 (14.8–29.3)/100 person-years. Only two serious ADRs (including one Stevens-Johnson syndrome case) occurred. The number needed to treat for preventing one PCP (52 (33–124)) was lower than the number needed to harm for serious ADR (131 (55–∞)). Conclusion TMP-SMX prophylaxis significantly reduces the PCP incidence with a favourable safety profile in patients with rheumatic disease receiving prolonged, high-dose steroids.
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Affiliation(s)
- Jun Won Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jinyoung Moon
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yeong Wook Song
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Suhnggwon Kim
- Division of Nephrology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.,Seoul Kidney Clinic, Seoul, Republic of Korea
| | - Eun Bong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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Lupus érythémateux systémique et lymphopénie : aspects cliniques et physiopathologiques. Rev Med Interne 2017; 38:603-613. [DOI: 10.1016/j.revmed.2017.01.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 01/07/2017] [Accepted: 01/11/2017] [Indexed: 12/20/2022]
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Khan BA, Khan S, White B, Eranki A. Severe pneumocystis jiroveci pneumonia in a patient on temozolomide therapy: A case report and review of literature. Respir Med Case Rep 2017; 22:179-182. [PMID: 28861334 PMCID: PMC5568882 DOI: 10.1016/j.rmcr.2017.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/31/2017] [Accepted: 08/11/2017] [Indexed: 11/17/2022] Open
Abstract
A 66 year old man was diagnosed with CNS diffuse large B-cell lymphoma, and underwent treatment with Temozolomide, Dexamethasone, Rituximab, and radiation therapy, and prolonged steroid taper with Dexamethasone. Approximately one month after this, he presented with severe acute hypoxemic respiratory failure, and was admitted to the Medical Intensive Care Unit. Imaging showed diffuse ground glass opacities. Patient underwent diagnostic bronchoalveolar lavage which was positive for Pneumocystis jiroveci. He did not respond well to appropriate therapy and was transitioned to comfort care per his family's wishes, and expired. Pneumocystis jiroveci should always be included in the differential diagnosis of pneumonia in patients treated with Temozolomide, especially when this agent is used in combination with long term, high dose corticosteroids and radiation therapy.
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Li J, Zhang Q, Su B. Clinical characteristics and risk factors of severe infections in hospitalized adult patients with primary nephrotic syndrome. J Int Med Res 2017; 45:2139-2145. [PMID: 28661269 PMCID: PMC5805218 DOI: 10.1177/0300060517715339] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objective Infection is a common condition in patients with nephrotic syndrome. The
objective of the present study is to investigate the clinical
characteristics and risk factors of infections in adult patients with
primary nephrotic syndrome (PNS). Methods Medical charts of 138 consecutive patients with PNS and infections who were
admitted to hospital from April 2013 to April 2016 were systematically
reviewed. Results Patients were divided into three groups according to the degree of
infections: mild infection group (n = 45), moderate infection group
(n = 60), and severe infection group (n = 33). In the severe infection
group, most patients (96.9%) had pulmonary infections with opportunistic
pathogens. There were significant differences in cumulative prednisone dose,
immunosuppressor use, and CD4+ T cell count among the three groups. A lower
CD4+ T cell count (<300 cells/mm3) (odds ratio = 4.25 [95%
confidence interval 1.680–10.98]) and higher cumulative dose of prednisone
(odds ratio = 1.38 [95% confidence interval 1.05–3.26]) were risk factors
for severe infections in adult patients with PNS. Conclusions CD4+ T cell count (<300 cells/mm3) and a higher cumulative dose
of prednisone are important risk factors for severe infections in adult
patients with PNS.
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Affiliation(s)
- Jie Li
- 1 Department of Nephrology, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Central Hospital, Lishui, Zhejiang, China
| | - Qiankun Zhang
- 1 Department of Nephrology, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Central Hospital, Lishui, Zhejiang, China
| | - Bofeng Su
- 2 Department of Nephrology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
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Chen CY, Weng YM, Chen JC. Pneumocystis Pneumonia Infection in a Survivor of Paraquat Intoxication. J Acute Med 2017; 7:75-78. [PMID: 32995175 PMCID: PMC7517916 DOI: 10.6705/j.jacme.2017.0702.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 09/12/2016] [Accepted: 10/03/2016] [Indexed: 06/11/2023]
Abstract
Patients who survived recent paraquat intoxication might be treated with glucocorticoid andcyclophosphamide to avoid further lung fi brosis. Such patients might be susceptible to opportunistic infections. Pneumocystis pneumonia (PCP) is an important opportunistic lung infection in hematologic malignancy patients on chemotherapy. We report a patient who recently survived paraquat intoxication and presented with acute respiratory insuffi ciency post glucocorticoid and cyclosporine treatment. A fulminant clinical course, and a clear medical history of immunocompromised state draw physician's attention to the possible opportunistic lung infection. PCP infection was confi rmed by a PCP deoxyribonucleic acid test. The symptoms improved markedly after appropriate antibiotics treatment. This report suggests that clinicians should consider PCP infection in patients who develop secondary pneumonia after paraquat intoxication. PCP treatment as part of empirical antibiotics should be added, especially in such patients presented with rapidly progressive course.
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Affiliation(s)
- Chih-Yu Chen
- Chang Gung Memorial Hospital and Chang Gung University College of Medicine Department of Emergency Medicine Linko Taiwan
| | - Yi-Ming Weng
- Chang Gung Memorial Hospital and Chang Gung University College of Medicine Department of Emergency Medicine Linko Taiwan
| | - Jih-Chang Chen
- Chang Gung Memorial Hospital and Chang Gung University College of Medicine Department of Emergency Medicine Linko Taiwan
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Li Y, Ghannoum M, Deng C, Gao Y, Zhu H, Yu X, Lavergne V. Pneumocystis pneumonia in patients with inflammatory or autoimmune diseases: Usefulness of lymphocyte subtyping. Int J Infect Dis 2017; 57:108-115. [PMID: 28223177 DOI: 10.1016/j.ijid.2017.02.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Revised: 02/12/2017] [Accepted: 02/13/2017] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES No consensus currently exists on the indications for Pneumocystis jirovecii prophylaxis in patients with inflammatory or autoimmune diseases. The main objective was to identify biomarkers associated with P. jirovecii pneumonia (PCP) in this population. METHODS A retrospective study was carried out at Beijing Union Medical College Hospital (2003-2014). All patients with an inflammatory or autoimmune disease presenting with acute onset of fever and respiratory symptoms were included. RESULTS A total of 123 patients were included, of whom 42% had confirmed PCP, 18% had possible PCP, and 40% were negative for PCP. Immunosuppressive conditions consisted mostly of diffuse connective tissue disease (50%) and primary nephropathy (20%). Immunosuppressive therapies consisted of corticosteroids (95%) with concomitant non-steroidal drugs (80%). Independent predictors of PCP were a CD3+ cell count <625×106/l, serum albumin <28g/l, and PaO2/FiO2 <210. Furthermore, 90% of patients with PCP had a CD3+ cell count <750×106/l. Independent predictors of mortality were a CD8+ cell count <160×106/l and a PaO2/FiO2 <160. CONCLUSIONS In patients with inflammatory and autoimmune conditions receiving immunosuppressive therapy, low CD3+ and CD8+ cell counts were strongly associated with PCP and its mortality. These results suggest that lymphocyte subtyping is a very useful tool to optimize the selection of patients needing prophylaxis.
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Affiliation(s)
- Yi Li
- Emergency Department, Peking Union Medical College Hospital, Beijing, China
| | - Marc Ghannoum
- Nephrology Department, Verdun Hospital, University of Montreal, Montreal, QC, Canada
| | - Chuntao Deng
- Emergency Department, Shenzhen Luohu People's Hospital, Shenzhen, China
| | - Yanxia Gao
- Emergency Department, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Huadong Zhu
- Emergency Department, Peking Union Medical College Hospital, Beijing, China
| | - Xuezhong Yu
- Emergency Department, Peking Union Medical College Hospital, Beijing, China
| | - Valery Lavergne
- Medical Microbiology and Infectious Diseases Department, Sacré-Cœur Hospital, University of Montreal, 5400 Boulevard Gouin Ouest, Montreal, QC, H2V 3A5, Canada.
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Fritzsche C, Ghanem H, Koball S, Mueller-Hilke B, Reisinger EC. High Pneumocystis jirovecii colonization rate among haemodialysis patients. Infect Dis (Lond) 2017; 49:132-136. [PMID: 27684384 DOI: 10.1080/23744235.2016.1225980] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Haemodialysis patients have been found to have an increased risk of developing Pneumocystis pneumonia (PcP) compared to the control population. To the best of our knowledge, no data are available on pulmonary colonization with Pneumocystis jirovecii in haemodialysis patients; therefore, the aim of this study was to determine the prevalence of pulmonary colonization with P. jirovecii in haemodialysis patients, and to find the related risk factors. Induced sputa of 62 haemodialysis patients were investigated using quantitative polymerase chain reaction for the presence of P. jirovecii. 20.9% of the patients were colonized with P. jirovecii and 46.2% of whom had CD4 cell counts below 400/μl. There was no significant correlation between colonization and time on dialysis treatment. As haemodialysis patients seem to be at higher risk of PcP than the general population, doctors should be aware of the high rate of P. jirovecii colonization amongst them. Furthermore, colonized patients remain a potential source of transmission of P. jirovecii to other patients or to health care workers.
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Affiliation(s)
- Carlos Fritzsche
- a Department of Medicine, Division of Tropical Medicine and Infectious Diseases , University of Rostock Medical School , Rostock , Germany
| | - Hosam Ghanem
- a Department of Medicine, Division of Tropical Medicine and Infectious Diseases , University of Rostock Medical School , Rostock , Germany
| | - Sebastian Koball
- b Department of Medicine, Division of Nephrology , University of Rostock Medical School , Rostock , Germany
| | - Brigitte Mueller-Hilke
- c Medical Faculty , Institute for Immunology, University of Rostock Medical School , Rostock , Germany
| | - Emil C Reisinger
- a Department of Medicine, Division of Tropical Medicine and Infectious Diseases , University of Rostock Medical School , Rostock , Germany
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Pneumocystis jirovecii pneumonia in patients with autoimmune disease on high-dose glucocorticoid. J Clin Rheumatol 2016; 21:72-5. [PMID: 25710857 DOI: 10.1097/rhu.0000000000000215] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Indications for Pneumocystis jirovecii pneumonia (PCP) prophylaxis in patients with autoimmune disease remain unclear. We aimed to determine (1) the incidence of PCP in patients with autoimmune disease in general, in a clinical setting where prophylaxis is not routine, and (2) whether high-dose glucocorticoid (≥30 mg oral prednisolone or equivalent per day) is a risk factor for PCP infection. METHODS A retrospective review of the medical records of patients with autoimmune diseases hospitalized to a tertiary center over a 5-year study period was carried out. Patient demographics, mean glucocorticoid dose (in the last 1 month), and the outcomes of patients who developed PCP were analyzed. RESULTS The incidence rate of PCP infection was 75 per 100,000 patients per year. The in-hospital mortality was 50%, and all those who died were on high-dose glucocorticoid at the time of PCP diagnosis. There was a significant difference between the occurrence of PCP in patients who were on high-dose vs non-high-dose glucocorticoid (df = 1, P = 0.009), with a relative risk of 19 (P = 0.010; 95% confidence interval, 2.0-182.8). The mean oral prednisolone dose of patients who developed PCP and those who did not were 55.5 versus 10.7 mg, respectively, P = 0.002. CONCLUSION High-dose glucocorticoid may be associated with an increased risk of PCP infection in patients with autoimmune diseases.
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Abstract
Corticosteroids are frequently used to treat rheumatic diseases. Their use comes with several well-established risks, including osteoporosis, avascular necrosis, glaucoma, and diabetes. The risk of infection is of utmost concern and is well documented, although randomized controlled trials of short-term and lower-dose steroids have generally shown little or no increased risk. Observational studies from the real world, however, have consistently shown dose-dependent increases in risk for serious infections as well as certain opportunistic infections. In patients who begin chronic steroid therapy, vaccination and screening strategies should be used in an attempt to mitigate this risk.
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Affiliation(s)
- Jameel Youssef
- Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA.
| | - Shannon A Novosad
- Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
| | - Kevin L Winthrop
- Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
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Papadopoulou D, Tsoulas C, Tragiannidis A, Sipsas NV. Role of vaccinations and prophylaxis in rheumatic diseases. Best Pract Res Clin Rheumatol 2015; 29:306-18. [PMID: 26362746 DOI: 10.1016/j.berh.2015.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 12/29/2014] [Accepted: 02/10/2015] [Indexed: 12/26/2022]
Abstract
Targeted strategies for reducing the increased risk of infection in patients with autoimmune rheumatic diseases include vaccinations as well as antibiotic prophylaxis in selected patients. However, there are still issues under debate: Is vaccination in patients with rheumatic diseases immunogenic? Is it safe? What is the impact of immunosuppressive drugs on vaccine immunogenicity and safety? Does vaccination cause disease flares? In which cases is prophylaxis against Pneumocystis jirovecii required? This review addresses these important questions to which clinicians and researchers still do not have definite answers. The first part includes immunization recommendations and reviews current data on vaccine efficacy and safety in patients with rheumatic diseases. The second part discusses prophylaxis for Pneumocystis pneumonia.
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Affiliation(s)
- Despoina Papadopoulou
- Pain and Palliative Care Unit, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Christos Tsoulas
- Institute for Continuing Medical Education of Ioannina, Ioannina, Greece.
| | - Athanassios Tragiannidis
- Hematology and Oncology Unit, Second Department of Pediatrics, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Nikolaos V Sipsas
- Infectious Disease Unit, Pathophysiology Department, Laikon General Hospital and Medical School, National and Kapodistrian University of Athens, Athens, Greece.
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Pneumocystis jirovecii pneumonia in mycophenolate mofetil-treated patients with connective tissue disease: analysis of 17 cases. Rheumatol Int 2014; 34:1765-71. [DOI: 10.1007/s00296-014-3073-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 05/26/2014] [Indexed: 11/26/2022]
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Roux A, Gonzalez F, Roux M, Mehrad M, Menotti J, Zahar JR, Tadros VX, Azoulay E, Brillet PY, Vincent F. Update on pulmonary Pneumocystis jirovecii infection in non-HIV patients. Med Mal Infect 2014; 44:185-98. [PMID: 24630595 DOI: 10.1016/j.medmal.2014.01.007] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Revised: 12/04/2013] [Accepted: 01/15/2014] [Indexed: 11/27/2022]
Abstract
Pneumocystis jirovecii is the only fungus of its kind to be pathogenic in humans. It is primarily responsible for pneumonia (PJP). The key to understanding immune defences has focused on T-cells, mainly because of the HIV infection epidemic. Patients presenting with PJP all have a CD4 count below 200/mm(3). The introduction of systematic primary prophylaxis and the use of new anti-retroviral drugs have significantly reduced the incidence of this disease in the HIV-infected population, mainly in developed countries. The increasingly frequent use of corticosteroids, chemotherapy, and other immunosuppressive drugs has led to an outbreak of PJP in patients not infected by HIV. These patients presenting with PJP have more rapid and severe symptoms, sometimes atypical, leading to delay the initiation of a specific anti-infective therapy, sometimes a cause of death. However, the contribution of new diagnostic tools and a better understanding of patients at risk should improve their survival.
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Affiliation(s)
- A Roux
- Service de pneumologie, hôpital Foch, 92151 Suresnes, France
| | - F Gonzalez
- Service de réanimation médico-chirurgicale, hôpital Avicenne, Assistance publique-Hôpitaux de Paris (AP-HP), 93009 Bobigny, France
| | - M Roux
- Service de radiologie, hôpital Avicenne, Assistance publique-Hôpitaux de Paris (AP-HP), 93009 Bobigny, France
| | - M Mehrad
- Service des urgences, Gustave Roussy, Cancer Campus Grand Paris, 94805 Villejuif, France
| | - J Menotti
- Service de parasitologie-mycologie, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris (AP-HP), 75010 Paris, France; Université Paris-Diderot, Sorbonne Paris-Cité, 75010 Paris, France
| | - J-R Zahar
- UPLIN, CHU d'Angers, 49100 Angers, France; Université d'Angers, 49100 Angers, France
| | - V-X Tadros
- Service de réanimation médico-chirurgicale, hôpital Avicenne, Assistance publique-Hôpitaux de Paris (AP-HP), 93009 Bobigny, France
| | - E Azoulay
- Service de réanimation médicale, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris (AP-HP), 75010 Paris, France; Université Paris-Diderot, Sorbonne Paris-Cité, 75010 Paris, France
| | - P-Y Brillet
- Service de radiologie, hôpital Avicenne, Assistance publique-Hôpitaux de Paris (AP-HP), 93009 Bobigny, France; Université Paris-13, 93009 Bobigny, France
| | - F Vincent
- Service de réanimation polyvalente, CHI Le Raincy-Montfermeil, 10, rue du Général-Leclerc, 93370 Montfermeil, France.
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Caza T, Oaks Z, Perl A. Interplay of Infections, Autoimmunity, and Immunosuppression in Systemic Lupus Erythematosus. Int Rev Immunol 2014; 33:330-63. [DOI: 10.3109/08830185.2013.863305] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Sciascia S, Cuadrado MJ, Karim MY. Management of infection in systemic lupus erythematosus. Best Pract Res Clin Rheumatol 2013; 27:377-89. [DOI: 10.1016/j.berh.2013.07.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Fritzsche C, Riebold D, Fuehrer A, Mitzner A, Klammt S, Mueller-Hilke B, Reisinger EC. Pneumocystis jiroveciicolonization among renal transplant recipients. Nephrology (Carlton) 2013; 18:382-7. [DOI: 10.1111/nep.12054] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Carlos Fritzsche
- Division of Tropical Medicine and Infectious Diseases; Department of Medicine; University of Rostock; Rostock; Germany
| | - Diana Riebold
- Division of Tropical Medicine and Infectious Diseases; Department of Medicine; University of Rostock; Rostock; Germany
| | - Andreas Fuehrer
- Division of Nephrology; Department of Medicine; University of Rostock; Rostock; Germany
| | - Andrea Mitzner
- Division of Nephrology; Department of Medicine; University of Rostock; Rostock; Germany
| | - Sebastian Klammt
- Division of Tropical Medicine and Infectious Diseases; Department of Medicine; University of Rostock; Rostock; Germany
| | | | - Emil C Reisinger
- Division of Tropical Medicine and Infectious Diseases; Department of Medicine; University of Rostock; Rostock; Germany
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De Vos FY, Gijtenbeek JM, Bleeker-Rovers CP, van Herpen CM. Pneumocystis jirovecii pneumonia prophylaxis during temozolomide treatment for high-grade gliomas. Crit Rev Oncol Hematol 2013; 85:373-82. [DOI: 10.1016/j.critrevonc.2012.08.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Revised: 07/23/2012] [Accepted: 08/02/2012] [Indexed: 12/24/2022] Open
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Pneumocystis jirovecii pneumonia manifesting as a lung abscess in a woman with systemic lupus erythematosus. Tzu Chi Med J 2012. [DOI: 10.1016/j.tcmj.2012.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Fritzsche C, Riebold D, Munk-Hartig AK, Klammt S, Neeck G, Reisinger EC. High prevalence ofPneumocystis jiroveciicolonization among patients with autoimmune inflammatory diseases and corticosteroid therapy. Scand J Rheumatol 2012; 41:208-13. [DOI: 10.3109/03009742.2011.630328] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Tsai MJ, Chou CW, Lin FC, Chang SC. Pneumocystis jiroveci pneumonia in patients with systemic lupus erythematosus after rituximab therapy. Lupus 2012; 21:914-8. [PMID: 22287506 DOI: 10.1177/0961203312436855] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pneumocystis jiroveci pneumonia (PCP) is an uncommon but potentially life-threatening infection in immunocompromised patients with low blood T cells. Rituximab, a chimeric human/murine monoclonal antibody against the B cell-specific antigen CD20, has been increasingly used and appears to be effective in the treatment of autoimmune disorders, including systemic lupus erythematosus (SLE). PCP has been reported in some patients with autoimmune diseases or lymphoma subjected to rituximab treatment, but has not yet been reported in SLE patients. We report PCP in two patients with SLE after rituximab treatment. Fever and respiratory symptoms associated with diffuse pulmonary infiltrates developed within weeks after rituximab therapy. One patient died of respiratory failure. Another patient recovered uneventfully after treatment with clindamycin and primaquine.
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Affiliation(s)
- M-J Tsai
- Department of Chest Medicine, Taipei Veterans General Hospital, Taiwan
| | - C-W Chou
- Department of Medical Affairs, Taipei Municipal Gan-Dau Hospital, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - F-C Lin
- Department of Chest Medicine, Taipei Veterans General Hospital, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - S-C Chang
- Department of Chest Medicine, Taipei Veterans General Hospital, Taiwan
- Institute of Emergency and Critical Care Medicine, National Yang-Ming University, Taipei, Taiwan
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Pneumocystis jirovecii pneumonia in non-HIV-infected patients: new risks and diagnostic tools. Curr Opin Infect Dis 2012; 24:534-44. [PMID: 21986616 DOI: 10.1097/qco.0b013e32834cac17] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW Non-HIV-infected populations are increasingly identified as being at risk for developing Pneumocystis jirovecii pneumonia (PJP). These patients typically present with severe disease and poorly tolerate invasive diagnostic procedures. This review examines recently reported risks for PJP in non-HIV populations and summarizes new diagnostic techniques. RECENT FINDINGS PJP is associated with immunomodulatory drug therapies, including monoclonal antibody therapies such as tumour necrosis factor α antagonists, and calcineurin inhibitors. Underlying disease states include solid-organ transplantation, connective tissue and rheumatologic disorders, inflammatory bowel disease, haematological malignancies, and solid tumours. Modern diagnostic techniques [conventional PCR, quantitative PCR, (1→3)-β-D-glucan assays, and PET] are reviewed with respect to predictive value and clinical utility. In particular, current literature regarding validation and specificity of molecular diagnostic techniques is summarized, including application to minimally invasive specimens. SUMMARY HIV-negative populations at risk for PJP can be identified. Conventional PCR increases diagnostic sensitivity but may detect asymptomatic colonization. Quantitative PCR demonstrates potential for distinguishing colonization from infection, but clinical validation is required. Serum (1→3)-β-D-glucan may be elevated in PJP, although standardized cut-off values for clinical infection have not been determined. Further validation of serum markers and molecular diagnostic methods is necessary for early and accurate diagnosis in non-HIV populations.
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Yang CY, Yang AH, Yang WC, Lin CC. Risk factors for Pneumocystis jiroveci pneumonia in glomerulonephritis patients receiving immunosuppressants. Intern Med 2012; 51:2869-75. [PMID: 23064560 DOI: 10.2169/internalmedicine.51.6774] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Pneumocystis jiroveci pneumonia (PJP) infection is a rare but lethal complication in immunocompromised hosts. However, risk factors for PJP infection in glomerulonephritis (GN) patients receiving immunosuppressants are unknown. METHODS From August 2009 to July 2010, we encountered a cluster occurrence of PJP infection in our renal biopsy patients. Seven of 73 GN patients under immunosuppressant agents developed PJP infection, which were diagnosed by the Giemsa and Gomori's methenamine silver stains of the bronchoalveolar lavage specimen. RESULTS The average time of PJP onset was 2.4 months after immunosuppressant initiation. We found that the immunosuppressant regimens were equal between patients with and without the development of PJP infection regarding the daily dose per body weight, treatment duration, and accumulative dose per body weight. Logistic regression analysis indicated that high serum creatinine, low hemoglobin, and low absolute lymphocyte count at immunosuppressant initiation, and high chronicity indices of kidney pathology were predictors of PJP infection. In addition, patients with PJP infection had persistently worse renal function, more severe anemia, and more severe lymphocytopenia as compared to those without. CONCLUSION Prophylactic therapy for P. jiroveci and immunosuppressant dose reduction should be considered in GN patients with high chronicity of their kidney diseases and/or persistent lymphocytopenia.
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Affiliation(s)
- Chih-Yu Yang
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taiwan
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Vananuvat P, Suwannalai P, Sungkanuparph S, Limsuwan T, Ngamjanyaporn P, Janwityanujit S. Primary Prophylaxis for Pneumocystis jirovecii Pneumonia in Patients with Connective Tissue Diseases. Semin Arthritis Rheum 2011; 41:497-502. [DOI: 10.1016/j.semarthrit.2011.05.004] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 05/13/2011] [Accepted: 05/22/2011] [Indexed: 11/28/2022]
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Role of primary prophylaxis for pneumocystis pneumonia in patients treated with systemic corticosteroids or other immunosuppressive agents for immune-mediated dermatologic conditions. J Am Acad Dermatol 2010; 63:815-23. [DOI: 10.1016/j.jaad.2009.11.588] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2009] [Revised: 11/17/2009] [Accepted: 11/22/2009] [Indexed: 11/20/2022]
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STAMP LISAK, HURST MIRIAM. Is There a Role for Consensus Guidelines forP. jiroveciPneumonia Prophylaxis in Immunosuppressed Patients with Rheumatic Diseases? J Rheumatol 2010; 37:686-8. [PMID: 20360202 DOI: 10.3899/jrheum.091426] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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