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Guo Q, Zhang X, Sun S, Tang X, Shen W, Liang J, Yao G, Geng L, Ding S, Chen H, Wang H, Hua B, Zhang H, Wang D, Feng X, Sun L, Jin Z. Association Between Mycophenolate Mofetil Use and Subsequent Infections Among Hospitalized Patients with Systemic Lupus Erythematosus: A Nested Case-Control Study. Rheumatol Ther 2023; 10:1535-1554. [PMID: 37742321 PMCID: PMC10654301 DOI: 10.1007/s40744-023-00595-5] [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: 07/08/2023] [Accepted: 08/22/2023] [Indexed: 09/26/2023] Open
Abstract
INTRODUCTION The association between mycophenolate mofetil (MMF) and infection in patients with systemic lupus erythematosus (SLE) has not been clarified. This study evaluated the degree and factors in effect of MMF use on infection in patients with SLE. METHODS A hospitalized-based observational study was conducted to collect medical records on patients with SLE during 2010-2021. A nested case-control study was performed among 3339 patients with SLE, including 1577 cases and 1762 controls by whether they developed any type of infection. The exposure of MMF use was determined within 1 year before diagnosed infection or the end of follow-up. Logistic regression was used to estimate the odds ratio (OR) and 95% confidence interval (CI) for association between MMF and subsequent infection. RESULTS MMF was significantly associated with the risk of overall infection (adjusted OR 1.90, 95% CI 1.48-2.44) and different types of infections, including bacterial infection (adjusted OR 2.07, 95% CI 1.55-2.75), viral infection (adjusted OR 1.92, 95% CI 1.23-3.01), and opportunistic infection (adjusted OR 2.13, 95% CI 1.31-3.46). The top three risks of specific types of infections were bacteremia/septicemia, urinary tract infection/pyelonephritis, and herpes zoster. Stratification analysis showed risk of overall infection increased especially in MMF users with age over 55 years, diabetes, central nervous system involvement, and thrombocytopenia. Moreover, the risk of infection increased with increasing dosage and duration of MMF use. Additionally, the combination of MMF with CYC and other immunosuppressants significantly increases the risk of infections compared to using a single one. CONCLUSIONS MMF use is associated with various type of infections in patients with SLE, particularly in those with longer use, older age, complications with comorbidities, and concomitant use of CYC or other immunosuppressants.
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Affiliation(s)
- Qingqing Guo
- Department of Rheumatology and Immunology, China Pharmaceutical University Nanjing Drum Tower Hospital, 321 Zhongshan Road, Nanjing, 210008, China
| | - Xueyi Zhang
- Department of Rheumatology and Immunology, China Pharmaceutical University Nanjing Drum Tower Hospital, 321 Zhongshan Road, Nanjing, 210008, China
| | - Siqin Sun
- Department of Rheumatology and Immunology, China Pharmaceutical University Nanjing Drum Tower Hospital, 321 Zhongshan Road, Nanjing, 210008, China
| | - Xiaojun Tang
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Wei Shen
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Jun Liang
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Genhong Yao
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Linyu Geng
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Shuai Ding
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Hongwei Chen
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Hong Wang
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Bingzhu Hua
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Huayong Zhang
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Dandan Wang
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Xuebing Feng
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
| | - Lingyun Sun
- Department of Rheumatology and Immunology, China Pharmaceutical University Nanjing Drum Tower Hospital, 321 Zhongshan Road, Nanjing, 210008, China.
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China.
- Rheumatology Medical Center and Stem Cell Intervention Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, China.
| | - Ziyi Jin
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China.
- Rheumatology Medical Center and Stem Cell Intervention Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, China.
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Burzio C, Balzani E, Corcione S, Montrucchio G, Trompeo AC, Brazzi L. Pneumocystis jirovecii Pneumonia after Heart Transplantation: Two Case Reports and a Review of the Literature. Pathogens 2023; 12:1265. [PMID: 37887781 PMCID: PMC10610317 DOI: 10.3390/pathogens12101265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/17/2023] [Accepted: 10/19/2023] [Indexed: 10/28/2023] Open
Abstract
Post-transplant Pneumocystis jirovecii pneumonia (PcP) is an uncommon but increasingly reported disease among solid organ transplantation (SOT) recipients, associated with significant morbidity and mortality. Although the introduction of PcP prophylaxis has reduced its overall incidence, its prevalence continues to be high, especially during the second year after transplant, the period following prophylaxis discontinuation. We recently described two cases of PcP occurring more than one year after heart transplantation (HT) in patients who were no longer receiving PcP prophylaxis according to the local protocol. In both cases, the disease was diagnosed following the diagnosis of a viral illness, resulting in a significantly increased risk for PcP. While current heart transplantation guidelines recommend Pneumocystis jirovecii prophylaxis for up to 6-12 months after transplantation, after that period they only suggest an extended prophylaxis regimen in high-risk patients. Recent studies have identified several new risk factors that may be linked to an increased risk of PcP infection, including medication regimens and patient characteristics. Similarly, the indication for PcP prophylaxis in non-HIV patients has been expanded in relation to the introduction of new medications and therapeutic regimens for immune-mediated diseases. In our experience, the first patient was successfully treated with non-invasive ventilation, while the second required tracheal intubation, invasive ventilation, and extracorporeal CO2 removal due to severe respiratory failure. The aim of this double case report is to review the current timing of PcP prophylaxis after HT, the specific potential risk factors for PcP after HT, and the determinants of a prompt diagnosis and therapeutic approach in critically ill patients. We will also present a possible proposal for future investigations on indications for long-term prophylaxis.
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Affiliation(s)
- Carlo Burzio
- Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza di Torino Hospital, 10126 Torino, Italy; (C.B.); (G.M.); (A.C.T.); (L.B.)
| | - Eleonora Balzani
- Department of Surgical Science, University of Turin, 10124 Torino, Italy
| | - Silvia Corcione
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10124 Turin, Italy;
- School of Medicine, Tufts University, Boston, MA 02111, USA
| | - Giorgia Montrucchio
- Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza di Torino Hospital, 10126 Torino, Italy; (C.B.); (G.M.); (A.C.T.); (L.B.)
- Department of Surgical Science, University of Turin, 10124 Torino, Italy
| | - Anna Chiara Trompeo
- Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza di Torino Hospital, 10126 Torino, Italy; (C.B.); (G.M.); (A.C.T.); (L.B.)
| | - Luca Brazzi
- Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza di Torino Hospital, 10126 Torino, Italy; (C.B.); (G.M.); (A.C.T.); (L.B.)
- Department of Surgical Science, University of Turin, 10124 Torino, Italy
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Clemente Garulo D, Núñez-Cuadros E, Camacho Lovillo M, Calzada-Hernández J, Guillén Martín S, Fernández Silveira L, Lirola Cruz MJ, Tagarro A, Alcobendas Rueda RM, López López A, Satrustegi Aritziturri M, Calvo C. Position statement on infection screening, prophylaxis, and vaccination in pediatric patients with rheumatic diseases and immunosuppressive therapies, part 2: infection prophylaxis. Eur J Pediatr 2023; 182:4271-4284. [PMID: 37439850 PMCID: PMC10570166 DOI: 10.1007/s00431-023-05080-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 06/18/2023] [Accepted: 06/21/2023] [Indexed: 07/14/2023]
Abstract
This study aims to provide practical recommendations on prophylaxis for infection in pediatric patients with immune-mediated rheumatic diseases receiving/scheduled to receive immunosuppressive therapy. A qualitative approach was applied. A narrative literature review was performed via Medline. Primary searches were conducted using MeSH terms and free text to identify articles that analyzed data on infections and vaccinations in pediatric patients with immune-mediated rheumatic diseases receiving immunosuppressive therapy. The results were presented and discussed in a nominal group meeting comprising a committee of 12 pediatric rheumatologists from the Prevention and Treatment of Infections Working Group of the Spanish Society of Pediatric Rheumatology. Several recommendations were generated. A consensus procedure was implemented via a Delphi process that was extended to members of the Spanish Society of Pediatric Rheumatology and the Vaccine Advisory Committee of the Spanish Association of Pediatrics. Participants produced a score ranging from 0 (completely disagree) to 10 (completely agree). Agreement was considered to have been reached if at least 70% of participants voted ≥ 7. The literature review included more than 400 articles. Overall, 63 recommendations were generated (23 on infection prophylaxis) and voted by 59 pediatric rheumatologists and other pediatric specialists, all of whom achieved the pre-established level of agreement. The recommendations on prophylaxis of infection cover vaccination and prophylaxis against varicella zoster virus, tuberculosis, Pneumocystis jiroveccii, and invasive fungal infections in pediatric patients with immune-mediated rheumatic diseases receiving/scheduled to receive immunosuppressive therapy. Conclusion: Based on current evidence and a Delphi process, we provided consensus and updated recommendations on prophylaxis and treatment of infections to guide those caring for pediatric rheumatology patients. What is Known: •Data largely derived from adults find that infectious diseases and related complications are a major cause of morbidity and mortality in patients with immune-mediated rheumatic diseases. •It is crucial to be aware of the preventive measures that should be implemented to prevent these infections in children, although most guidelines are often extrapolated from adult cases. What is New: •In the absence of evidence, a literature review and a Delphi survey were conducted to establish a series of expert recommendations that could prove useful in clinical practice, providing a practical and simple day-to-day approach to be used by pediatric rheumatologists. •The recommendations focus on tuberculosis, herpes zoster virus, fungal infections, and Pneumocystis jirovecii.
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Affiliation(s)
| | - Esmeralda Núñez-Cuadros
- Pediatric Rheumatology Unit, UGC Pediatría, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Av. del Arroyo de los Ángeles, S/N, 29011, Málaga, Spain.
| | - Marisol Camacho Lovillo
- Servicio de Inmunología, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBIS), Reumatología E Infectología Pediátricas, Seville, Spain
| | - Joan Calzada-Hernández
- Unitat de Reumatologia Pediàtrica, Servei de Pediatria, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
| | - Sara Guillén Martín
- Department of Paediatrics, Hospital Universitario de Getafe, Getafe, Madrid, Spain
| | - Laura Fernández Silveira
- Servicio de Inmunología, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBIS), Reumatología E Infectología Pediátricas, Seville, Spain
| | - María José Lirola Cruz
- Department of Paediatric Rheumatology, Instituto Hispalense de Pediatría, Seville, Spain
| | - Alfredo Tagarro
- Pediatrics Department, Instituto de Investigación 12 de Octubre (imas12), Hospital Universitario Infanta Sofía, Universidad Europea, Hospital 12 de Octubre, Madrid, Spain
| | | | - Agustín López López
- Department of Paediatrics, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | | - Cristina Calvo
- Department of Pediatrics, Infectious and Tropical Diseases, Hospital Universitario La Paz, and La Paz Research Institute (IdiPaz), Madrid, Spain
- Translational Research Network of Pediatric Infectious Diseases (RITIP). Madrid, Madrid, Spain
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Matsumoto K, Suzuki K, Yasuoka H, Hirahashi J, Yoshida H, Magi M, Noguchi-Sasaki M, Kaneko Y, Takeuchi T. Longitudinal monitoring of circulating immune cell phenotypes in anti-neutrophil cytoplasmic antibody-associated vasculitis. Autoimmun Rev 2023; 22:103271. [PMID: 36627064 DOI: 10.1016/j.autrev.2023.103271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 01/05/2023] [Indexed: 01/09/2023]
Abstract
Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a necrotizing multiorgan autoimmune disease that affects small- to medium-sized blood vessels. Despite the improvements in treatments, half of the patients with AAV still experience disease relapses. In this review, we focus on peripheral leukocyte properties and phenotypes in patients with AAV. In particular, we explore longitudinal changes in circulating immune cell phenotypes during the active phase of the disease and treatment. The numbers and phenotypes of leukocytes in peripheral blood were differs between AAV and healthy controls, AAV in active versus inactive phase, AAV in treatment responders versus non-responders, and AAV with and without severe infection. Therefore, biomarkers detected in peripheral blood immune cells may be useful for longitudinal monitoring of disease activity in AAV.
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Affiliation(s)
- Kotaro Matsumoto
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan.
| | - Katsuya Suzuki
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hidekata Yasuoka
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan; Division of Rheumatology, Department of Internal Medicine, Fujita Health University School of Medicine, Aichi, Japan
| | - Junichi Hirahashi
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | | | - Mayu Magi
- Chugai Pharmaceutical Co. Ltd., Kanagawa, Japan
| | | | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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Sun Y, Shao C, Huang H, Chen R, Xu K, Li M, Zhang X, Xu Z. Prognostic Analysis of Pneumocystis Jirovecii Pneumonia in Interstitial Lung Disease Patients: A Retrospective Clinical Study. Diagnostics (Basel) 2022; 12:2925. [PMID: 36552932 PMCID: PMC9777515 DOI: 10.3390/diagnostics12122925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/16/2022] [Accepted: 11/22/2022] [Indexed: 11/25/2022] Open
Abstract
(1) Background: The clinical characteristics and the prognostic factors of HIV-negative Pneumocystis jirovecii pneumonia (PJP) patients (non-HIV-PJP) with interstitial lung disease (ILD) remain unclear. Our objectives were to describe the clinical characteristics and to explore the prognostic factors of non-HIV-ILD-PJP patients. (2) Methods: The enrolled patients in this retrospective study were stratified based on the presence or absence of ILD and fibrotic ILD (FILD). The log-rank test and Cox regression models were used to analyze the prognostic factors. (3) Results: Among 378 non-HIV-PJP patients, there were 133 patients with ILD-PJP, and 70 patients were classified as having FILD-PJP. The all-cause mortality rate for the ILD-PJP group is higher than that of the ILD-PJP group (57.9% vs. 38.4%, p < 0.001). However, the all-cause mortality is similar between the FILD-PJP group and non-FILD-PJP group. Preexisting ILD (HR: 2.156, p = 0.003) and honeycomb appearance on the chest HRCT (HR = 16.3, p < 0.001) are independent survival risk factors for ILD-PJP. Non-invasive ventilation is an independent survival risk factor for ILD-PJP patients (HR = 928.56, p < 0.01) and FILD-PJP patients (HR = 33.86, p < 0.001). (4) Conclusions: Pre-existing ILD and honeycomb appearance on the chest HRCT are independent survival risk factors for PJP patients. Non-invasive ventilation is associated with poor survival for both ILD-PJP and FILD-PJP patients.
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Affiliation(s)
- Yuxin Sun
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan Street, Dongcheng District, Beijing 100730, China
- Department of Anesthesiology, China-Japan Friendship Hospital, No. 2 Yinghua East Street, Chaoyang District, Beijing 100029, China
| | - Chi Shao
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan Street, Dongcheng District, Beijing 100730, China
| | - Hui Huang
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan Street, Dongcheng District, Beijing 100730, China
| | - Ruxuan Chen
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan Street, Dongcheng District, Beijing 100730, China
| | - Kai Xu
- Radiological Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan Street, Dongcheng District, Beijing 100730, China
| | - Mei Li
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan Street, Dongcheng District, Beijing 100730, China
| | - Xin Zhang
- Medical Records Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan Street, Dongcheng District, Beijing 100730, China
| | - Zuojun Xu
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan Street, Dongcheng District, Beijing 100730, China
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Belov BS, Egorova ON, Tarasova GM, Muravieva NV. Infections and systemic vasculitis. MODERN RHEUMATOLOGY JOURNAL 2022. [DOI: 10.14412/1996-7012-2022-5-75-81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Infections and systemic vasculitis (SV) are characterized by mutual influence, which increases the risk of occurrence, aggravates the course and outcome of the disease. The review considers the issues related to both the trigger role of infections in the development of SV and comorbid infections (CI) that complicate the course of the disease. Recognition of the infectious etiology of SV is of great importance, since it requires a comprehensive examination and, if necessary, early and complete etiotropic treatment. Since SV per se and the use of both induction and maintenance immunosuppressive therapy are significant risk factors for secondary CIs, special attention should be paid to the prevention of the latter, including vaccination, primarily against influenza and pneumococcal infections.
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Affiliation(s)
- B. S. Belov
- V.A. Nasonova Research Institute of Rheumatology
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Huang YM, Lu CH, Cheng CF, Shen CY, Hsieh SC, Li KJ, Chien JY, Hsueh PR. Clinical features and prognostic predictors in patients with rheumatic diseases complicated by Pneumocystis pneumonia. Int J Infect Dis 2022; 122:1018-1025. [DOI: 10.1016/j.ijid.2022.07.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/19/2022] [Accepted: 07/27/2022] [Indexed: 10/16/2022] Open
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Huang L, Fu Q, Ye Y, Lin Y, Yan Q, Chen S. High incidence and mortality of Pneumocystis jirovecii infection in anti-MDA5-antibody-positive dermatomyositis: experience from a single center. Arthritis Res Ther 2021; 23:232. [PMID: 34481528 PMCID: PMC8417987 DOI: 10.1186/s13075-021-02606-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 08/14/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Idiopathic inflammatory myopathies (IIM) are associated with a significantly higher risk of opportunistic infections including Pneumocystis jirovecii pneumonia (PJP), a potentially fatal opportunistic infection. However, no prior studies have evaluated PJP infection in subtypes of IIM. OBJECTIVES To investigate the prevalence and mortality rate of PJP infection in subgroups of IIM patients stratified according to myopathy-specific antibodies. METHODS In the first part of the study, 463 consecutive patients with IIM were prospectively followed for a period of at least 1 year to analyze the incidence of PJP. In the second part of the study, we enrolled 30 consecutive PJP patients with any rheumatic disease in order to identify the mortality rate and risk factors by Cox regression analysis. The Kaplan-Meier method with log-rank testing was used to assess differences in survival. RESULTS The prevalence of PJP in IIM patients was found to be 3.0/100 person-years, while in MDA5+ DM patients it was 7.5/100 person-years and in MDA5- IIM patients 0.7/100 person-years (P < 0.05). PJP typically occurred in the first 2 months in the case of MDA5+ DM patients who had a significant decrease in their CD4+ T cell counts and lymphocyte counts (P < 0.05). In PJP patients, 3-month mortality was higher for MDA5+ DM patients than in those with other rheumatic diseases (83.3% vs 38.9%, P < 0.05). Alarmingly, MDA5+ DM patients seemed not to benefit from prompt anti-PJP treatment, unlike patients with other rheumatic diseases whose survival improved when anti-PJP treatment was started within 6 days (P < 0.05). CONCLUSION PJP has an alarming high incidence and mortality in MDA5+ DM patients. Timely treatment for PJP seems not to improve the prognosis of patients with this particular subtype. Hence, there remains a crucial unmet need to develop PJP prophylaxis for MDA5+ DM patients.
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Affiliation(s)
- Linlin Huang
- Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200001, China
| | - Qiong Fu
- Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200001, China
| | - Yan Ye
- Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200001, China
| | - Yanwei Lin
- Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200001, China
| | - Qingran Yan
- Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200001, China.
| | - Sheng Chen
- Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200001, China.
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Ishikawa Y, Nakano K, Tokutsu K, Miyata H, Fujino Y, Matsuda S, Tanaka Y. Estimation of treatment and prognostic factors of pneumocystis pneumonia in patients with connective tissue diseases. RMD Open 2021; 7:rmdopen-2020-001508. [PMID: 33688083 PMCID: PMC7944977 DOI: 10.1136/rmdopen-2020-001508] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/05/2021] [Accepted: 02/22/2021] [Indexed: 11/23/2022] Open
Abstract
Objectives To investigate short-term prognosis and prognostic factors for connective tissue disease-associated pneumocystis pneumonia (CTD-PCP) using the Japanese nationwide diagnosis procedure combination (DPC) inpatient database. Methods The present retrospective cohort study from April 2014 to March 2016 included data of patients with CTD-PCP extracted from the DPC database using the 10th revision of International Classification of Diseases and Injuries codes. Results In 15 901 766 cases registered from 1329 hospitals, 333 of 67 890 patients who were admitted with PCP were diagnosed with CTD-PCP and included in the study. The median age was 71.0 years, and 214 (64.3%), 80 (24.0%), and 29 (8.7%) patients received sulfamethoxazole/trimethoprim (ST) monotherapy and pentamidine-containing and atovaquone-containing therapy, respectively. There were 114 (34.2%) in-hospital deaths, and the 30-day and 60-day in-hospital survival rates after PCP treatment initiation were 66.0% and 53.7%, respectively. Older age (HR 1.06, 95% CI 1.03 to 1.08) and concomitant interstitial lung disease (ILD) (HR 1.65, 95% CI 1.12 to 2.42) were poor prognostic factors. Patients who completed PCP treatment with ST monotherapy had a significantly higher survival rate than those treated with those not treated with ST monotherapy (p=0.015; log-rank test). Pentamidine versus atovaquone as second-line therapy was significantly higher with atovaquone (p=0.012; log-rank test). Conclusion Older age and concomitant ILD were poor prognostic factors for CTD-PCP. ST was a reasonable first-line therapy in patients with CTD-PCP, and patients with inadequate response to ST treated with atovaquone tended to have a better prognosis than those treated with pentamidine.
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Affiliation(s)
- Yuichi Ishikawa
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan.,Department of Rheumatology, Yokohama Rosai Hospital, Yokohama, Japan.,Sato Clinic, Tokyo, Japan
| | - Kazuhisa Nakano
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Kei Tokutsu
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health Japan, Kitakyushu, Fukuoka, Japan
| | - Hiroko Miyata
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Yoshihisa Fujino
- Department of Environmental Epidemiology, University of Occupational and Environmental Health Japan, Kitakyushu, Japan
| | - Shinya Matsuda
- Department of Environmental Epidemiology, University of Occupational and Environmental Health Japan, Kitakyushu, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
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Oku K, Hamijoyo L, Kasitanon N, Li MT, Navarra S, Morand E, Tanaka Y, Mok CC. Prevention of infective complications in systemic lupus erythematosus: A systematic literature review for the APLAR consensus statements. Int J Rheum Dis 2021; 24:880-895. [PMID: 33999518 DOI: 10.1111/1756-185x.14125] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 04/18/2021] [Indexed: 12/28/2022]
Abstract
Systemic lupus erythematosus (SLE) is a more common autoimmune rheumatic disease in the Asia-Pacific region. The prognosis of SLE remains unsatisfactory in some Asian countries because of delayed diagnosis, limited access to medications, increased complications and issues of tolerability and adherence to treatment. The Asia-Pacific League of Associations for Rheumatology SLE special interest group has recently published a set of consensus recommendations on the management of SLE for specialists, family physicians, specialty nurses, and other healthcare professionals in the Asia-Pacific region. This article reports a systematic literature review of the infective complications of SLE in Asia and evidence for prevention of these infections by pre-emptive antimicrobial therapy and vaccination.
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Affiliation(s)
- Kenji Oku
- Department of Rheumatology, Endocrinology and Nephrology Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Laniyati Hamijoyo
- Rheumatology Division, Department of Internal Medicine, Padjadjaran University, Bandung, Indonesia
| | - Nuntana Kasitanon
- Division of Rheumatology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Meng Tao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
| | - Sandra Navarra
- Section of Rheumatology, University of Santo Tomas Hospital, Manila, Philippines
| | - Eric Morand
- Centre for Inflammatory Diseases, Monash University School of Clinical Sciences, Monash Medical Centre, Melbourne, Vic., Australia
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Chi Chiu Mok
- Division of Rheumatology, Department of Medicine, Tuen Mun Hospital, Hong Kong, Hong Kong
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11
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Pneumocystis jirovecii pneumonia in autoimmune rheumatic diseases: a nationwide population-based study. Clin Rheumatol 2021; 40:3755-3763. [PMID: 33646447 PMCID: PMC7917170 DOI: 10.1007/s10067-021-05660-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 02/08/2021] [Accepted: 02/16/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To compare Pneumocystis jirovecii pneumonia (PJP) risk between patients with autoimmune rheumatic diseases (ARD) and the general population METHODS: We identified patients with ARD recorded in the National Health Insurance Research Database of Taiwan from 2002 to 2015 and randomly selected a comparison cohort from the general population matched for age and sex. We analyzed PJP risk stratified by sex, age, comorbidities, and medications using Cox proportional hazard model. RESULTS We enrolled 103,117 patients with ARD. PJP risk significantly increased in patients with any ARD and with each individual ARD like rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Sjogren's syndrome (SjS), polymyositis and dermatomyositis (PM/DM), systemic sclerosis (SSc), and systemic vasculitis. Patients with PM/DM showed prominent risk with incidence rate of 12.47/100,000 patient year (95% confidence interval (CI), 32.16-86.70). In a time-dependent Cox proportional hazard model with comorbidities and medications as covariates, PM/DM, SSc, SLE, and SjS significantly increased adjusted hazard ratios (aHR) of 5.40, 5.12, 4.09, and 3.64, respectively (95% CI of 2.82-10.35, 2.16-12.13, 2.41-6.95, and 2.06-6.42, respectively). AHR after adjusting for male sex, cancer, human immunodeficiency virus infection (HIV), and interstitial lung disease also significantly increased. Use of daily oral steroid dose of >10 mg conferred the highest risk followed by mycophenolate. Use of injected steroids, cyclophosphamide, biological agents, methotrexate, and cyclosporine conferred a significantly higher risk. CONCLUSION Underlying ARD significantly predisposes patients to PJP, with PM/DM posing the highest threat. In addition to underlying disease, comorbidities and concomitant immunosuppressants are major risks. The strongest risk is recent daily steroid dose of >10 mg. Mycophenolate seems to be a more prominent risk factor than cyclophosphamide. Key Points • Autoimmune rheumatic diseases (ARD) significantly increased the overall risk of PJP, and so did each individual ARD. • Use of steroids, mycophenolate, cyclophosphamide, biological agents, methotrexate, and cyclosporine all significantly increased risk of PJP. • Male, elderly, malignancy, HIV, and interstitial lung disease are also related to increased risk of PJP. • Underlying ARD, comorbidities, and use of immunosuppressant should all be considered in determining the overall risk of PJP.
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12
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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: 8] [Impact Index Per Article: 2.7] [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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13
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Cassone G, Sebastiani M, Vacchi C, Erre GL, Salvarani C, Manfredi A. Efficacy and safety of mycophenolate mofetil in the treatment of rheumatic disease-related interstitial lung disease: a narrative review. Drugs Context 2021; 10:dic-2020-8-8. [PMID: 33505480 PMCID: PMC7813435 DOI: 10.7573/dic.2020-8-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/26/2020] [Indexed: 12/13/2022] Open
Abstract
Mycophenolate mofetil (MMF) is an antimetabolite with a potent inhibitory effect on proliferation of T and B lymphocytes used since the early 1990s for the prevention of acute allograft rejection after organ transplant. MMF is also widely used for the treatment of a variety of rheumatic diseases (RDs) and their pulmonary involvement. Interstitial lung disease (ILD) is a heterogeneous group of progressive fibrotic diseases of the lung, which is often secondary to RD and represents a major cause of morbidity and mortality. MMF is considered the main alternative to cyclophosphamide as a first-line agent to treat RD-related ILD or as possible maintenance therapy after cyclophosphamide, with a lower rate of side-effects. However, as for other immunosuppressive agents, the use of MMF in RD-ILD is supported by poor scientific evidence. In this narrative review, we describe the available data and recent advances on the effectiveness and safety of MMF for the treatment of ILD related to RD, including rheumatoid arthritis, systemic sclerosis, primary Sjögren syndrome, systemic lupus erythematosus, idiopathic inflammatory myopathies, undifferentiated connective tissue disease, interstitial pneumonia with autoimmune features and antineutrophil cytoplasmic antibody-associated vasculitis.
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Affiliation(s)
- Giulia Cassone
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy.,Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy.,Rheumatology Unit, IRCCS Arcispedale Santa Maria Nuova, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Marco Sebastiani
- Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
| | - Caterina Vacchi
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy.,Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
| | - Gian Luca Erre
- Rheumatology Unit, Azienda Ospedaliero-Universitaria di Sassari, Sassari, Italy
| | - Carlo Salvarani
- Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy.,Rheumatology Unit, IRCCS Arcispedale Santa Maria Nuova, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Andreina Manfredi
- Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
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14
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Pneumocystis Pneumonia and the Rheumatologist: Which Patients Are At Risk and How Can PCP Be Prevented? Curr Rheumatol Rep 2018; 19:35. [PMID: 28488228 DOI: 10.1007/s11926-017-0664-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Immunosuppressive therapy for connective tissue diseases (CTDs) is steadily becoming more intense. The resultant impairment in cell-mediated immunity has been accompanied by an increasing risk for opportunistic infection (OI). Pneumocystis pneumonia (PCP) has been recognized as an OI in patients with CTDs, but specific risk factors and precise indications for PCP prophylaxis remain poorly defined. This review was undertaken to update information on the risk of PCP in patients with CTDs and to examine current guidelines for PCP prophylaxis in this population. RECENT FINDINGS Data on the occurrence of PCP and indications for prophylaxis in patients with CTDs is sparse. Large systematic reviews did not incorporate patients with CTD secondary to the lack of randomized control trials. Upon reviewing guidelines published since 2015, prophylaxis for PCP is recommended only for patients with ANCA-positive vasculitis, specifically granulomatosis with polyangiitis (GPA), who are undergoing intense induction therapy. Evidence-based recommendations for the prophylaxis of PCP in patients with CTDs cannot be provided. There is expert consensus that PCP prophylaxis is warranted in patients with GPA undergoing induction therapy. Prophylaxis should perhaps also be considered for other CTD patients who are receiving similar intense immunosuppressive therapy especially if they are lymphopenic or have a low CD4 count.
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15
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Isak V, Jorizzo JL. Recent developments on treatment strategies and the prognosis of dermatomyositis: a review. J DERMATOL TREAT 2017; 29:450-459. [DOI: 10.1080/09546634.2017.1403549] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Verena Isak
- Department of Dermatology, Wake Forest School of Medicine, Winston Salem, New York, NY, USA
- Medical University of Vienna, Vienna, Austria
| | - Joseph L. Jorizzo
- Department of Dermatology, Wake Forest School of Medicine, Winston Salem, New York, NY, USA
- Department of Dermatology, Weill Cornell Medical College, New York, NY, USA
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16
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Mori S, Sugimoto M. Pneumocystis jirovecii Pneumonia in Rheumatoid Arthritis Patients: Risks and Prophylaxis Recommendations. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2015; 9:29-40. [PMID: 26396551 PMCID: PMC4562607 DOI: 10.4137/ccrpm.s23286] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 08/03/2015] [Accepted: 08/06/2015] [Indexed: 01/05/2023]
Abstract
Pneumocystis jirovecii infection causes fulminant interstitial pneumonia (Pneumocystis pneumonia, PCP) in patients with rheumatoid arthritis (RA) who are receiving biological and/or nonbiological antirheumatic drugs. Recently, we encountered a PCP outbreak among RA outpatients at our institution. Hospital-acquired, person-to-person transmission appears to be the most likely mode of this cluster of P. jirovecii infection. Carriage of P. jirovecii seems a time-limited phenomenon in immunocompetent hosts, but in RA patients receiving antirheumatic therapy, clearance of this organism from the lungs is delayed. Carriers among RA patients can serve as sources and reservoirs of P. jirovecii infection for other susceptible patients in outpatient facilities. Development of PCP is a matter of time in such carriers. Considering the poor survival rates of PCP cases, prophylactic antibiotics should be considered for RA patients who are scheduled to receive antirheumatic therapy. Once a new case of PCP occurs, we should take prompt action not only to treat the PCP patient but also to prevent other patients from becoming new carriers of P. jirovecii. Short-term prophylaxis with trimethoprim-sulfamethoxazole is effective in controlling P. jirovecii infection and preventing future outbreaks of PCP among RA patients.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Diseases, NHO Kumamoto Saishunsou National Hospital, Kumamoto, Japan
| | - Mineharu Sugimoto
- Division of Respiratory Medicine, Department of Medicine, Social Insurance Omuta Tenryo Hospital, Fukuoka, Japan
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17
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DeFilippis EM, Shaikh F, DeMauro A, Scherl EJ, Bosworth BP. Pneumocystis jiroveci pneumonia with recurrent pneumothorax requiring pleurodesis in inflammatory bowel disease. J Dig Dis 2015; 16:416-9. [PMID: 25940201 DOI: 10.1111/1751-2980.12257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Ersilia M DeFilippis
- Department of Medicine, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Faisal Shaikh
- Department of Medicine, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Amanda DeMauro
- Department of Medicine, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Ellen J Scherl
- Department of Medicine, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Brian P Bosworth
- Department of Medicine, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
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