Effects of corticosteroids treatment in patients with Severe Fever with Thrombocytopenia Syndrome:A single-center retrospective cohort study

Impact of Glucocorticoid Therapy on 28-Day Mortality in Patients Having Severe Fever with Thrombocytopenia Syndrome in an Intensive Care Unit: A Retrospective Analysis

Purpose

The high mortality rate associated with the critical stages of severe fever with thrombocytopenia syndrome (SFTS) does not have effective treatment. We aimed to evaluate the 28-day mortality and potential impact of glucocorticoid therapy in these patients.

Patients and Methods

This retrospective observational study included participants from the intensive care unit between July 2019 and April 2023. The participants were categorized into glucocorticoid (GC) and non-GC groups. Propensity score matching (PSM) was employed to ensure comparability between groups. We used Cox proportional hazard models to examine mortality risk associated with GC use, Kaplan-Meier survival analyses for overall survival, stratified Cox proportional hazard models for subgroup analyses, and likelihood ratio tests to examine interactions between subgroups.

Results

Of 218 patients with SFTS (median age, 71 years; male, 49.1%), 61.9% required mechanical ventilation, 58.3% received GC treatment, and the 28-day mortality rate was 61.5%. After PSM, there were 58 patients in each group; post-PSM analysis revealed improved 28-day mortality rates with GC treatment, particularly for patients with Glasgow coma scale (GCS) score <13 (hazard ratio [HR], 95% confidence interval [CI] for GCS score: 9-12: 0.39, 0.17-0.88, p=0.024 and for GCS score: 3-8: 0.09, 0.02-0.35, p=0.001); lactate levels >2 mmol/L (0.35, 0.15-0.83, p=0.017); and norepinephrine usage (0.26, 0.13-0.49, p<0.001). Combining antiviral (0.41, 0.22-0.78, p=0.006) or immunoglobulin therapy (0.22, 0.1-0.51, p<0.001) with GC treatment significantly decreased the 28-day mortality rates, compared with GC monotherapy.

Conclusion

Using GCs reduced the high 28-day mortality rate in the patients, especially with low GCS score, high lactate levels, norepinephrine intake, and on antiviral or immunoglobulin therapy.

Early predictors of Epstein-Barr virus infection in patients with severe fever with thrombocytopenia syndrome

BACKGROUND

Epstein-Barr virus (EBV) can be reactivated and proliferated with fatal outcome in immuno-compromised people, but the clinical consequences of EBV infection in patients with severe fever with thrombocytopenia syndrome (SFTS) remain uncertain. In this study, we investigated the infection rate, the influence and the early predictors of EBV infection in SFTS patients.

METHODS

In this retrospective study, SFTS patients who were treated in the First Affiliated Hospital of Nanjing Medical University from May 2011 to August 2021 were enrolled and divided into infected and non-infected groups. We compared the demographic characteristics, clinical manifestations and signs, laboratory tests and prognosis, and explored the risk factors of EBV infection by receiver operating characteristic (ROC) curve and logistic regression.

RESULTS

A total of 120 hospitalized SFTS patients with EBV-DNA testing were enrolled in this study. Patients with EBV infection had statistically significant higher mortality rate (32.0% vs. 11.43%, P = 0.005). Compared with the non-infected group, the EBV-infected group had higher levels of C-reactive protein (CRP), creatine-kinase (CK), fasting blood glucose (FBG), blood urea nitrogen (BUN), D-dimer, and CD56+ cell counts, lower levels of immunoglobulin G (IgG), IgM, complement 3 (C3), and C4. The proportion of patients with age ≥ 60 years and ferritin > 1500.0 ng/ml in the EBV-infected group was significantly higher than that in the non-infected group. The results of ROC analysis showed that the cut-off values of CRP, IgG, C3, C4, and CD56+ cell counts to predict EBV infection were 13.2 mg/l, 12.5 g/l, 1.1 g/l, 0.6 g/l, 0.3 g/l, and 94.0 cells/µl. Multivariable logistic analysis showed that age ≥ 60 years old, CRP > 13.2 mg/l, BUN > 5.4 mmol/l, ferritin > 1500.0 ng/ml, IgG < 12.5 g/l, IgM < 1.1 g/l, C4 < 0.3 g/l, and CD56+ cell counts > 94.0 cells/µl were the independent risk factors of EBV infection in SFTS patients.

CONCLUSIONS

SFTS combined with EBV infection is associated with high morbidity and mortality. It is necessary to strengthen screening for EBV infection and its early predictive markers after admission in SFTS patients.

The use of glucocorticoid in severe fever with thrombocytopenia syndrome: a retrospective cohort study

Introduction

Severe fever with thrombocytopenia syndrome (SFTS) is prevalent in East Asia. However, the use of glucocorticoids (GCs) in the treatment of SFTS remains controversial.

Methods

In this retrospective cohort study, we collected the data from patients with SFTS at Wuhan Union Hospital to evaluate the effect of GC therapy. Mortality and secondary infections were compared as outcomes. After searching public databases, we also included articles that examined GC use in patients with SFTS for meta-analysis.

Results

Patients treated with GC had higher fatality rates (21.1% vs. 11.9%, respectively; P=0.006) and a longer length of stay (10.6 ± 5.1 vs. 9.5 ± 4.2, respectively; P=0.033). In cohorts adjusted using propensity score matching and inverse probability of treatment weighting, no significant differences in fatality rates and length of stay were observed. A meta-analysis of 4243 SFTS patient revealed that those treated with GCs had significantly higher mortality (OR=3.46, 95% CI =2.12-5.64, P<0.00001) and secondary infection rate (OR=1.97, 95% CI=1.45-2.67, P<0.0001).

Discussion

GC should be used cautiously when treating SFTS. No significant differences were identified in terms of mortality and secondary infection rates between patients with SFTS treated with or without GC.

N-glycosylation of viral glycoprotein is a novel determinant for the tropism and virulence of highly pathogenic tick-borne bunyaviruses

Severe fever with thrombocytopenia syndrome (SFTS) virus, a tick-borne bunyavirus, causes a severe/fatal disease termed SFTS; however, the viral virulence is not fully understood. The viral non-structural protein, NSs, is the sole known virulence factor. NSs disturbs host innate immune responses and an NSs-mutant SFTS virus causes no disease in an SFTS animal model. The present study reports a novel determinant of viral tropism as well as virulence in animal models, within the glycoprotein (GP) of SFTS virus and an SFTS-related tick-borne bunyavirus. Infection with mutant SFTS viruses lacking the N-linked glycosylation of GP resulted in negligible usage of calcium-dependent lectins in cells, less efficient infection, high susceptibility to a neutralizing antibody, low cytokine production in macrophage-like cells, and reduced virulence in Ifnar-/- mice, when compared with wildtype virus. Three SFTS virus-related bunyaviruses had N-glycosylation motifs at similar positions within their GP and a glycan-deficient mutant of Heartland virus showed in vitro and in vivo phenotypes like those of the SFTS virus. Thus, N-linked glycosylation of viral GP is a novel determinant for the tropism and virulence of SFTS virus and of a related virus. These findings will help us understand the process of severe/fatal diseases caused by tick-borne bunyaviruses.

Ruxolitinib plus standard of care in severe hospitalized adults with severe fever with thrombocytopenia syndrome (SFTS): an exploratory, single-arm trial

BACKGROUND

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging tick-borne infectious disease, and its morbidity and mortality are increasing. At present, there is no specific therapy available. An exacerbated IFN-I response and cytokine storm are related to the mortality of patients with SFTS. Ruxolitinib is a Janus kinase (JAK) 1/2 inhibitor that can block proinflammatory cytokines and inhibit the type I IFN pathway. We aimed to explore the use of ruxolitinib plus standard of care for severe SFTS.

METHODS

We conducted a prospective, single-arm study of severe SFTS. We recruited participants aged 18 years or older who were admitted to the hospital with laboratory-confirmed severe SFTS and whose clinical score exceeded 8 points within 6 days of symptom onset. Participants received oral ruxolitinib (10 mg twice a day) for up to 10 days. The primary endpoint was 28-day overall survival. The secondary endpoints included the proportion of participants who needed intensive care unit (ICU) admission, total cost, changes in neurologic symptoms and clinical laboratory parameters, and adverse events (AEs) within 28 days. A historical control group (HC group, n = 26) who met the upper criteria for inclusion and hospitalized from April 1, 2021, to September 16, 2022, was selected and 1:1 matched for baseline characteristics by propensity score matching.

RESULTS

Between Sep 16, 2022, and Sep 16, 2023, 26 participants were recruited into the ruxolitinib treatment group (RUX group). The 28-day overall mortality was 7.7% in the RUX group and 46.2% in the HC group (P = 0.0017). There was a significantly lower proportion of ICU admissions (15.4% vs 65.4%, p < 0.001) and total hospitalization cost in the RUX group. Substantial improvements in neurologic symptoms, platelet counts, hyperferritinemia, and an absolute decrease in the serum SFTS viral load were observed in all surviving participants. Treatment-related adverse events were developed in 6 patients (23.2%) and worsened in 8 patients (30.8%), and no treatment-related serious adverse events were reported.

CONCLUSIONS

Our findings indicate that ruxolitinib has the potential to increase the likelihood of survival as well as reduce the proportion of ICU hospitalization and being tolerated in severe SFTS. Further trials are needed.

TRAIL REGISTRATION

ChiCTR2200063759, September 16, 2022.

Effect of fasting plasma glucose level in severe fever and thrombocytopenia syndrome patients without diabetes

Hyperglycemia is correlated with worse in-hospital outcomes in acute infectious diseases such as coronavirus disease 2019 (COVID-19) and severe fever with thrombocytopenia syndrome (SFTS). This study assessed the relationship between fasting plasma glucose (FPG) levels and in-hospital mortality, disease type, and secondary infections among individuals with SFTS without preexisting diabetes. The clinical data and laboratory results upon admission of 560 patients with SFTS without preexisting diabetes meeting the inclusion criteria at Wuhan Union Hospital were collected. FPG levels in surviving patients with SFTS subjects were significantly lower than those in patients with SFTS who had died (P<0.0001). In multivariate Cox regression, high FPG level (≥11.1 mmol/L) was a risk factor independently associated with the in-hospital death of patients with SFTS without preexisting diabetes. Similarly, the FPG levels in general patients with SFTS were significantly lower than those in patients with severe SFTS (P<0.0001). Multivariate logistic regression identified high FPG level (7.0-11.1 mmol/L) as a risk factor independently associated with SFTS severity. While FPG levels were comparable between patients with SFTS with and without secondary infection (P = 0.5521), logistic regression analysis revealed that high FPG levels were not a risk factor for secondary infection in patients with SFTS without preexisting diabetes. High FPG level on admission was an independent predictor of in-hospital death and severe disease in individuals with SFTS without preexisting diabetes. FPG screening upon admission and glycemic control are effective methods for improving the prognosis of patients with SFTS.

High CRP/PNI levels predict an unfavorable prognosis in severe fever with thrombocytopenia syndrome: A propensity score matching study

BACKGROUND

This study aimed to identify a novel inflammatory index and construct a nomogram for predicting in-hospital mortality due to severe fever with thrombocytopenia syndrome (SFTS).

METHODS

This cohort included 610 patients with SFTS hospitalized in Wuhan Union Hospital between March 2017 and November 2022. The ratio of C-reactive protein (CRP) to the prognostic nutritional index (PNI) was calculated and used to reflect patients' inflammatory status. Propensity score matching (PSM) was utilized to balance confounding factors between the low- and high-CRP/PNI groups. SFTS individuals from Jinyinhu Hospital were used as the validation cohort.

RESULTS

Patients with SFTS and high CRP/PNI were significantly correlated with a higher percentage of severe and critical SFTS types and higher in-hospital mortality rates than those with low CRP/PNI. CRP/PNI was the potent risk indicator for in-hospital mortality in individuals with SFTS. The CRP/PNI nomogram showed a good predictive value for in-hospital mortality in patients with SFTS. After PSM, the predictive performance of CRP/PNI for 28-day mortality was excellent. Finally, the CRP/PNI could still assess patients with SFTS at different risks based on SFTS data from another medical center.

CONCLUSION

The CPR/PNI ratio exhibited a strong positive correlation with the SFTS disease type and could predict in-hospital mortality in the early stages of SFTS. The CPR/PNI ratio could substantially help clinicians facilitate the early identification of patients with high-risk SFTS and the timely initiation of intensive therapy.

Corticosteroid Therapy for Patients With Severe Fever With Thrombocytopenia Syndrome: A Nationwide Propensity Score-Matched Study in Japan

Background

Severe fever with thrombocytopenia syndrome (SFTS) is a life-threatening infectious disease for which no effective treatment strategy has been established. Although corticosteroids (CSs) are widely administered to patients with SFTS, their efficacy remains uncertain. This study aimed to assess the impact of CS therapy on the in-hospital mortality of patients with SFTS.

Methods

In this nationwide observational study using the Japanese Diagnosis Procedure Combination database, patients hospitalized for SFTS from April 2013 to March 2021 were reviewed. We compared patients who were treated with CSs to those who were treated without them after propensity score matching to adjust for their background, disease severity, and combination therapy.

Results

We included 494 patients with SFTS, and 144 pairs of them were analyzed after propensity score matching. No significant difference in the 30-day mortality (19% vs 15%, P = .272) and the number of survival days (log-rank test, P = .392) was found between the CS treatment group and the non-CS treatment group. However, in subgroup analyses, the CS treatment group tended to have better survival among patients with impaired consciousness on admission and/or shock status within 7 days after admission.

Conclusions

CS therapy does not seem effective for all patients with SFTS; however, the impact might be altered by disease severity assessed by the consciousness level and shock status. A large-scale interventional study is required to determine its efficacy, especially for critically ill patients with SFTS.