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Zhang H, Yue J, Hou X, Lu H, Bikdeli A, Guo H, Li H, Li D. Rapidly progressive interstitial lung disease combined with pneumocystis jiroveci pneumonia in a patient with single anti-TIF-1γ antibody positive dermatomyositis in the context of an underlying tumor. BMC Pulm Med 2023; 23:248. [PMID: 37415133 DOI: 10.1186/s12890-023-02542-0] [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: 03/20/2023] [Accepted: 06/28/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND Interstitial lung disease (ILD) is a frequently observed comorbidity in autoimmune diseases such as dermatomyositis/polymyositis (DM/PM), and it is significantly associated with specific autoantibody types. One unique antibody type is the anti-transcription intermediate factor-1γ antibody (anti-TIF-1γ Ab), which has a positive rate of only 7%. It is often found in combination with malignancy and rarely with ILD, particularly rapidly progressive ILD (RPILD). In some cases, the presence of ILD in individuals with DM may indicate a paraneoplastic syndrome. Pneumocystis jiroveci pneumonia (PJP) typically occurs due to intensive immunosuppressive therapy, human immunodeficiency virus (HIV) infection, or malignancy, and rarely as an isolated condition. CASE PRESENTATION A 52-year-old man with a history of rapid weight loss but non-HIV infected and not immunosuppressed who presented with fever, cough, dyspnea, weakness of the extremities, characteristic rash and mechanic's hand. Pathogenic tests suggested PJP, laboratory tests suggested a single anti-TIF-1γ Ab positive DM, imaging suggested ILD, and pathology revealed no malignancy. RPILD and acute respiratory distress syndrome (ARDS) developed after anti-infection and steroid hormone therapy. After mechanical support therapy such as Extracorporeal Membrane Oxygenation (ECMO), the patient developed late-onset cytomegalovirus pneumonia (CMVP), complicated bacterial infection, and ultimately death. Additionally, we discuss the potential causes of rapid weight loss, the mechanisms by which anti-TIF-1γ Ab may lead to ILD, and the possible connection between anti-TIF-1γ Ab positivity, rapid weight loss, immune abnormalities, and opportunistic infections. CONCLUSIONS This case emphasizes the importance of early recognition of malignant tumors and pulmonary lesions, assessment of the body's immune status, prompt initiation of immunosuppressive treatment, and prevention of opportunistic infections in individuals with single anti-TIF-1γ Ab positive DM presenting with rapid weight loss.
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Affiliation(s)
- Hengzhe Zhang
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China
- Department of Intensive Care Medicine, Qilu Hospital, Shandong University, Jinan, 250012, Shandong, China
| | - Jinfeng Yue
- Department of Intensive Care Medicine, Qilu Hospital, Shandong University, Jinan, 250012, Shandong, China
| | - Xiaohui Hou
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China
- Department of Intensive Care Medicine, Qilu Hospital, Shandong University, Jinan, 250012, Shandong, China
| | - Hongjun Lu
- Department of Intensive Care Medicine, Traditional Chinese Medicine of Rizhao Hospital, Rizhao, 276800, Shandong, China
| | - Arezou Bikdeli
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China
| | - Haipeng Guo
- Department of Intensive Care Medicine, Qilu Hospital, Shandong University, Jinan, 250012, Shandong, China
| | - Hao Li
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, 250012, Shandong, China
| | - Daqing Li
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China.
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Hsu HC, Huang PW, Cho YT, Chu CY. Cotrimoxazole as a Preventative Intervention for Pneumocystis Pneumonia in Pemphigus Patients Treated with Rituximab: A Retrospective Study. Dermatol Ther (Heidelb) 2023:10.1007/s13555-023-00953-9. [PMID: 37322166 DOI: 10.1007/s13555-023-00953-9] [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: 05/05/2023] [Accepted: 05/30/2023] [Indexed: 06/17/2023] Open
Abstract
INTRODUCTION Pneumocystis jirovecii pneumonia (PJP) is a severe, life-threatening complication in patients treated with rituximab. However, there is no consensus on the primary prophylaxis for it in rituximab-treated pemphigus patients. Therefore, we sought to investigate the prophylactic efficacy and safety profile of cotrimoxazole for reducing the risk of developing PJP in pemphigus patients receiving rituximab. METHODS This single-center retrospective study investigated 148 pemphigus patients undergoing a first cycle of rituximab between 2008 and 2021 at a tertiary referral center in northern Taiwan. Patients were divided into the prophylaxis group (N = 113) and the control group (N = 35) according to whether or not cotrimoxazole was administered. The primary outcome was the 1-year incidence of PJP in the two groups, while the secondary outcome was the incidence of cotrimoxazole-related adverse events. RESULTS Of the 148 patients enrolled in this study, three patients, all in the control group, developed PJP during the 1-year follow-up. The incidence of PJP (8.6%) in the control group was significantly higher than that in the prophylaxis group (0%) (p = 0.012). The incidence of cotrimoxazole-related adverse events was 2.7%, and none of the cases were associated with life-threatening conditions. In addition, the cumulative prednisolone dose was associated with a trend of a higher risk of PJP (p = 0.0483). CONCLUSIONS Prophylactic cotrimoxazole significantly reduces the risk of PJP in a certain high-risk population and has a tolerable safety profile.
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Affiliation(s)
- Hao-Chen Hsu
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung-Shan South Road, Taipei, Taiwan
| | - Po-Wei Huang
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung-Shan South Road, Taipei, Taiwan
- Department of Surgery and Section of Dermatology, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Yung-Tsu Cho
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung-Shan South Road, Taipei, Taiwan
| | - Chia-Yu Chu
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung-Shan South Road, Taipei, Taiwan.
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Varghese JA, Guhan S, Zheng L. Emerging Fungal Infections and Cutaneous Manifestations in Immunosuppressed Patients. CURRENT DERMATOLOGY REPORTS 2023. [DOI: 10.1007/s13671-023-00386-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
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4
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Retrospective analysis of risks and benefits of trimethoprim/sulfamethoxazole as prophylaxis for Pneumocystis jiroveci pneumonia in patients with dermatologic disease. J Am Acad Dermatol 2023:S0190-9622(23)00194-9. [PMID: 36796726 DOI: 10.1016/j.jaad.2023.01.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/07/2022] [Accepted: 01/15/2023] [Indexed: 02/17/2023]
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5
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Song S, Zhang Y, Yu J, Xie C, Chen Y, Zhang X. Time to trimethoprim/sulfamethoxazole initiation among patients with rheumatic disease complicated by Pneumocystis jirovecii pneumonia: impact on 90-day mortality. BMC Infect Dis 2022; 22:961. [PMID: 36575406 PMCID: PMC9793549 DOI: 10.1186/s12879-022-07940-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 12/12/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PJP) is a life-threatening disease with increasing prevalence in patients with rheumatic disease. Trimethoprim/sulfamethoxazole (TMP/SMX) is an effective treatment for patients with rheumatic disease hospitalized for PJP. This study aimed to describe the 90-day mortality of patients with rheumatic disease complicated by PJP and investigate whether the administration of TMP/SMX after 7 days from initial symptoms correlates with 90-day mortality. METHODS We enrolled consecutive patients with rheumatic disease complicated with PJP in our center from August 2018 to August 2021. The participants were classified into two groups according to when TMP/SMX was initiated: early (within the first 7 days) and late (after 7 days). The primary outcome was 90-day PJP-related mortality. Multivariate cox regression and Kaplan-Meier survival analyses were conducted to identify the risk factors for mortality and examine differences in survival between early and late use of TMP/SMX. RESULTS Thirty-seven patients with rheumatic disease (median age 50.1 years, 24.3% male) complicated by PJP were enrolled in our study, and 15 (40.5%) patients died at or before 90 days of follow-up. The most common comorbidity was systemic lupus erythematosus (14, 37.8%), followed by inflammatory myopathy (11, 27.9%). Patients in the early group were less likely to require mechanical ventilation (8/27, 29.6% vs. 9/10, 90.0%, P = 0.002), lower doses glucocorticoids (43.2 mg/d vs. 72.2 mg/d, P = 0.039) and had lower mortality (7/27, 25.9% vs. 8/10, 80.0%, P = 0.006) than those in the late group. In the Kaplan-Meier analysis, the survivor probability of the early group was notably higher than that of the late group (P = 0.007). Multivariate cox regression analysis showed that initiation of TMP/SMX after 7 days from admission (hazard ratio [HR]: 5.9, 95% confidence interval [CI]: 1.1-30.4; P = 0.034) and a higher level of lactate dehydrogenase (LDH; HR: 6.0, 95% CI: 1.1-31.8; P = 0.035) were associated with 90-day mortality in patients with rheumatic disease complicated by PJP. CONCLUSION Patients with rheumatic disease complicated by PJP had poor prognoses, with mortality rates as high as 40.5%. TMP/SMX initiation after 7 days from initial symptoms and a higher level of serum LDH were significantly associated with increased 90-day mortality.
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Affiliation(s)
- Siyang Song
- grid.415869.7Department of Emergency, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai, China
| | - Yang Zhang
- grid.415869.7Department of Emergency, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai, China
| | - Jie Yu
- grid.415869.7Department of Emergency, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai, China
| | - Cuiying Xie
- grid.415869.7Department of Emergency, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai, China
| | - Yi Chen
- grid.415869.7Department of Emergency, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai, China
| | - Xingyu Zhang
- grid.415869.7Department of Emergency, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai, China
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Borojevic B, Johns E, Raju N, Sycamnias LA. Pneumocystis pneumonia with respiratory failure in a HIV-negative patient following short course of low-dose to moderate-dose prednisolone for a dermatological condition. BMJ Case Rep 2022; 15:e249346. [PMID: 35675962 PMCID: PMC9185496 DOI: 10.1136/bcr-2022-249346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2022] [Indexed: 12/15/2022] Open
Abstract
A woman in her 80s was admitted with 5 days of progressive dyspnoea and hypoxic respiratory failure, in the setting of receiving a 3-week course of low-dose to moderate-dose prednisolone for a pruritic skin rash. Her medical history was not significant for major medical comorbidities or any other clear risk factors for secondary immunosuppression apart from advanced age. CT revealed widespread small-airway and parenchymal disease with ground-glass opacities consistent with atypical respiratory infection. Sputum PCR confirmed Pneumocystis jirovecii She was diagnosed with Pneumocystis jirovecii pneumonia (PJP) in the context of her clinical presentation, radiological features and PCR result. Her HIV status was negative. The patient was treated with 4 weeks of trimethoprim-sulfamethoxazole and 3 weeks of adjunctive prednisolone. She initially required high-dependency unit support with non-invasive ventilation. In this case report, we review the literature regarding PJP in the dermatology setting.
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Affiliation(s)
- Branko Borojevic
- General Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Esther Johns
- General Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Nihal Raju
- General Medicine, Austin Health, Heidelberg, Victoria, Australia
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Watanabe Y, Hayashi K, Terai S. A Rare Case of Ulcerative Colitis with Severe Pneumocystis jirovecii Pneumonia and Cytomegalovirus Colitis: A Case Report and Literature Review. Intern Med 2022; 61:339-344. [PMID: 34373380 PMCID: PMC8866792 DOI: 10.2169/internalmedicine.7953-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Pneumocystis jirovecii pneumonia (PJP) and cytomegalovirus (CMV) colitis are opportunistic infections that occur during immunosuppressive treatments for ulcerative colitis (UC). The prognosis of PJP and CMV colitis is very poor. We herein report a rare case of a 74-year-old UC patient with PJP and CMV colitis that was successfully treated with intensive therapy. PJP progresses rapidly, so the timing and choice of treatment are critical. Furthermore, a literature review of similar cases suggested that prophylactic therapy for opportunistic infections might be important, especially in the elderly. This case will serve as a reference for successful treatment in future cases.
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Affiliation(s)
- Yusuke Watanabe
- Division of Preemptive Medicine for Digestive Disease and Healthy Active Life, School of Medicine, Niigata University, Japan
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Japan
| | - Kazunao Hayashi
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Japan
- Department of Preventive and Minimally Invasive Medicine for Digestive Desease, Niigata University, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Japan
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8
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Faraji H, Daneshpazhooh M, Ehsani AH, Mahmoudi H, Tavakolpour S, Aryanian Z, Aslani S, Khodaveisi H, Balighi K. Evaluating the risk-to-benefit ratio of using cotrimoxazole as a pneumocystis pneumonia preventative intervention among pemphigus patients treated with rituximab: A retrospective study with 494 patients. Dermatol Ther 2021; 35:e15257. [PMID: 34890103 DOI: 10.1111/dth.15257] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/27/2021] [Accepted: 12/04/2021] [Indexed: 11/28/2022]
Abstract
Rituximab is widely used as the first-line treatment for pemphigus patients. Since it depletes the B cells, it increases the risk of infections. Here, we evaluated the prophylactic efficacy of cotrimoxazole in decreasing the risk of pneumocystis pneumonia (PCP) infection in the pemphigus patients treated with rituximab. The medical records of confirmed pemphigus patients receiving rituximab were evaluated in two groups; those who received cotrimoxazole as a prophylactic after rituximab and patients who only received rituximab without any prophylaxis. The occurrence of PCP infection was determined in each group and compared. Medical records of 494 patients, including 301 women and 193 men, with the mean age of 46.74 years were analyzed. The phenotypes of the disease were mucocutaneous (n = 364), mucosal (n = 88), and cutaneous (n = 42). Among them, 235 cases had received cotrimoxazole as a prophylaxis and 259 patients did not. The incidence of PCP in total patients was 2 (0.4%), one in each group. Accordingly, no significant difference was observed in the incidence of PCP between two groups (p = 0.84). Also, no cotrimoxazole-related side effect was observed in the treated group. It seems that due to the low incidence of PCP in pemphigus patients treated with rituximab, prophylactic cotrimoxazole therapy is not necessary and it only increases the overall therapy cost and might cause cotrimoxazole-related adverse effects in some patients. However, regarding its probable beneficial effect in patients with long-term history of immunosuppressive therapy, more studies are required.
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Affiliation(s)
- Hannaneh Faraji
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Daneshpazhooh
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Hooshang Ehsani
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Mahmoudi
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Soheil Tavakolpour
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Zeinab Aryanian
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Department of Dermatology, Babol University of Medical Sciences, Babol, Iran
| | - Saeed Aslani
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Khodaveisi
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Kamran Balighi
- Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Malik AM, Tupchong S, Huang S, Are A, Hsu S, Motaparthi K. An Updated Review of Pemphigus Diseases. Medicina (B Aires) 2021; 57:medicina57101080. [PMID: 34684117 PMCID: PMC8540565 DOI: 10.3390/medicina57101080] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/26/2021] [Accepted: 09/28/2021] [Indexed: 01/19/2023] Open
Abstract
Clinicians may encounter a variety of skin conditions that present with vesiculobullous lesions in their everyday practice. Pemphigus vulgaris, pemphigus foliaceus, IgA pemphigus, and paraneoplastic pemphigus represent the spectrum of autoimmune bullous dermatoses of the pemphigus family. The pemphigus family of diseases is characterized by significant morbidity and mortality. Considering the risks associated with a delayed diagnosis or misdiagnosis and the potential for overlap in clinical features and treatment, evaluation for suspected pemphigus disease often requires thorough clinical assessment and laboratory testing. Diagnosis is focused on individual biopsies for histopathology and direct immunofluorescence. Additional laboratory methods used for diagnosis include indirect immunofluorescence and enzyme-linked immunosorbent assay. Recent advancements, including anti-CD20 therapy, have improved the efficacy and reduced the morbidity of pemphigus treatment. This contribution presents updates on the pathophysiology, clinical features, diagnostic work-up, and medical management of pemphigus. Improved strategies for diagnosis and clinical assessment are reviewed, and newer treatment options are discussed.
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Affiliation(s)
- Ali M. Malik
- College of Medicine, University of Florida, Gainesville, FL 32606, USA; (A.M.M.); (A.A.)
| | - Sarah Tupchong
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA;
| | - Simo Huang
- Department of Dermatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA; (S.H.); (S.H.)
| | - Abhirup Are
- College of Medicine, University of Florida, Gainesville, FL 32606, USA; (A.M.M.); (A.A.)
| | - Sylvia Hsu
- Department of Dermatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA; (S.H.); (S.H.)
| | - Kiran Motaparthi
- Department of Dermatology, College of Medicine, University of Florida, Gainesville, FL 32606, USA
- Correspondence:
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Intraepithelial autoimmune bullous dermatoses disease activity assessment and therapy. J Am Acad Dermatol 2021; 84:1523-1537. [PMID: 33684497 DOI: 10.1016/j.jaad.2021.02.073] [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: 05/03/2020] [Revised: 02/19/2021] [Accepted: 02/21/2021] [Indexed: 12/30/2022]
Abstract
Intraepithelial autoimmune blistering dermatoses are a rare group of skin disorders characterized by disruptions of inter-keratinocyte connections within the epidermis through the action of autoantibodies. The second article in this continuing medical education series presents validated disease activity scoring systems, serologic parameters of disease, treatments, and clinical trials for pemphigus and its subtypes.
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11
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Kokubu H, Kato T, Nishikawa J, Tanaka T, Fujimoto N. Adverse effects of trimethoprim–sulfamethoxazole for the prophylaxis of
Pneumocystis
pneumonia in dermatology. J Dermatol 2021; 48:542-546. [DOI: 10.1111/1346-8138.15724] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 11/10/2020] [Accepted: 11/21/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Hiraku Kokubu
- Department of Dermatology Shiga University of Medical Science Otsu Shiga Japan
| | - Takeshi Kato
- Department of Dermatology Shiga University of Medical Science Otsu Shiga Japan
| | - Junko Nishikawa
- Department of Dermatology Shiga University of Medical Science Otsu Shiga Japan
| | - Toshihiro Tanaka
- Department of Dermatology Shiga University of Medical Science Otsu Shiga Japan
| | - Noriki Fujimoto
- Department of Dermatology Shiga University of Medical Science Otsu Shiga Japan
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12
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Thomas RM, Colon A, Motaparthi K. Rituximab in autoimmune pemphigoid diseases: Indications, optimized regimens, and practice gaps. Clin Dermatol 2019; 38:384-396. [PMID: 32563354 DOI: 10.1016/j.clindermatol.2019.07.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Rituximab is a monoclonal antibody targeting CD20 on B cells with proven efficacy for pemphigus vulgaris, now an FDA-approved indication. Other autoimmune bullous diseases can be challenging to treat and have significant associated morbidity and mortality, but data supporting the use of rituximab in pemphigoid group diseases remain limited. Although rituximab demonstrates efficacy for clinical improvement and remission in pemphigoid, concern for adverse events may also limit the use of this medication. We review the current evidence fo rthe use of rituximab in pemphigoid diseases, pertinent dosing schedules and laboratory monitoring, and the associated common and rare adverse events. Review of the literature to date not only supports consideration of rituximab for treatment of refractory pemphigoid group diseases but also reflects tolerability and an acceptable safety profile.
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Affiliation(s)
- Renee M Thomas
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Alysha Colon
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Kiran Motaparthi
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA.
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13
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Rekhtman S, Strunk A, Garg A. Incidence of pneumocystosis among patients exposed to immunosuppression. J Am Acad Dermatol 2019; 80:1602-1607. [DOI: 10.1016/j.jaad.2018.12.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 12/20/2018] [Accepted: 12/27/2018] [Indexed: 11/29/2022]
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14
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Bakker DS, Garritsen FM, Leavis HL, van der Schaft J, Bruijnzeel-Koomen CAFM, van den Broek MPH, de Bruin-Weller MS. Lymphopenia in atopic dermatitis patients treated with oral immunosuppressive drugs. J DERMATOL TREAT 2018. [PMID: 29526121 DOI: 10.1080/09546634.2018.1451619] [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: 10/17/2022]
Abstract
INTRODUCTION Oral immunosuppressive drugs are commonly used in the treatment of atopic dermatitis (AD). In patients with autoimmune- and rheumatic diseases, these drugs have been associated with lymphopenia. Lymphopenia is related to an increased risk of opportunistic infections. The incidence of lymphopenia in patients with AD treated with oral immunosuppressive drugs is yet unknown. OBJECTIVE To evaluate the occurrence of recurrent lymphopenia in patients with AD treated with oral immunosuppressive drugs and to make recommendations for screening in daily practice. METHODS Patients with recurrent lymphopenia (i.e. >5 times lymphocyte counts below 0.8 × 109/L) during treatment with oral immunosuppressive drugs were included from our immunosuppressive drugs database and further analyzed. RESULTS A total of 360 AD patients, treated with oral immunosuppressive drugs, were screened. A recurrent lymphopenia during treatment was found in 11 patients. In 8/11 patients, recurrent lymphopenia was observed during concomitant treatment with prednisone. No serious infections were observed. CONCLUSION Lymphopenia is occasionally seen in AD patients treat with oral immunosuppressive drugs. Concomitant treatment with prednisone seems to be a risk factor. We suggest to include monitoring of lymphocyte counts in the standard follow-up for all AD patients treated with oral immunosuppressive drugs.
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Affiliation(s)
- Daphne S Bakker
- a Department of Dermatology , University Medical Center Utrecht , Utrecht , The Netherlands
| | - Floor M Garritsen
- a Department of Dermatology , University Medical Center Utrecht , Utrecht , The Netherlands
| | - Helen L Leavis
- b Department of Rheumatology and Clinical Immunology , University Medical Center Utrecht , Utrecht , The Netherlands
| | - Jorien van der Schaft
- a Department of Dermatology , University Medical Center Utrecht , Utrecht , The Netherlands
| | | | - Marcel P H van den Broek
- c Department of Clinical Pharmacy , University Medical Center Utrecht , Utrecht , The Netherlands.,d Department of Clinical Pharmacy , St Antonius Hospital , Nieuwegein , The Netherlands
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Amber KT, Lamberts A, Solimani F, Agnoletti AF, Didona D, Euverman I, Cozzani E, Yueh LH, Di Zenzo G, Leshem YA, Mimouni D, Hertl M, Horvath B. Determining the Incidence of Pneumocystis Pneumonia in Patients With Autoimmune Blistering Diseases Not Receiving Routine Prophylaxis. JAMA Dermatol 2017; 153:1137-1141. [PMID: 28854309 PMCID: PMC5710438 DOI: 10.1001/jamadermatol.2017.2808] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 06/14/2017] [Indexed: 12/25/2022]
Abstract
Importance Pneumocystis pneumonia (PCP) is a potentially lethal opportunistic infection that primary prophylaxis can help prevent. The risk of prophylactic therapy must be weighed against the incidence of PCP in the patient population. Prophylaxis most frequently involves trimethoprim-sulfamethoxazole, with second-line therapies, including atovaquone, dapsone, and pentamide. The indication for prophylaxis in immunocompromised patients without HIV is less well defined. Previously, an incidence of at least 3.5% has been proposed as a cutoff to justify prophylaxis. Objective To assess the incidence of PCP in patients with autoimmune blistering diseases receiving no routine prophylaxis. Design, Setting, and Participants This was a retrospective analysis of patient medical records to determine the incidence of PCP infections. The multicenter study was performed at tertiary care centers that provide care for patients with autoimmune blistering disease in Germany, Italy, Singapore, Israel, and the Netherlands. Patients had a confirmed diagnosis of pemphigus vulgaris/foliaceus, bullous pemphigoid, epidermolysis bullosa acquisita, mucous membrane pemphigoid/cicatricial pemphigoid, or anti-p200 pemphigoid. Main Outcomes and Measures To determine the incidence of PCP defined as patients with the International Classification of Diseases, Ninth Revision (ICD-9), code 136.3, for PCP, or free text documentation of PCP occurring based on characteristic radiographic findings with elevated lactate dehydrogenase, or hospitalization for pneumonia with bronchioalveolar lavage demonstrating Pneumocystis jiroveci on confirmatory stains. Results A total of 801 patients with autoimmune blistering diseases were included in this study; their mean (SD) age was 66.5 (17.6) years, and a total of 465 (58%) were female. Only 1 patient developed PCP, resulting in an incidence rate of 0.1%. This incidence significantly fell below the recommended threshold of 3.5% (0.1% vs 3.5%, χ21 = 27.0; P < .001). This incidence was significantly lower than the previously reported incidence of PCP in all immunosuppressed dermatologic patients (0.1% vs 1.3%; χ21 = 8.2; P = .004). Conclusions and Relevance Routine Pneumocystis prophylaxis for patients with autoimmune blistering diseases does not seem to be warranted. Patients with autoimmune blistering disease seem to have a lower risk of PCP than the general population of immunosuppressed dermatology patients. Risks of routine prophylaxis include hyperkalemia, hypoglycemia, photosensitivity, thrombocytopenia, and more rare adverse reactions.
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Affiliation(s)
- Kyle T. Amber
- Department of Dermatology, University of California, Irvine
| | - Aniek Lamberts
- Center for Blistering Diseases, Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Farzan Solimani
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany
| | - Arianna F. Agnoletti
- Department of Dermatology, University of California, Irvine
- DISSAL Section of Dermatology, IRCCS Azienda Universitaria Ospedaliera San Martino-IST, Genoa, Italy
| | - Dario Didona
- Dermatology Division, Istituto Dermopatico Dell’Immacolata, IDI-IRCCS, FLMM, Rome, Italy
| | - Ilona Euverman
- Center for Blistering Diseases, Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Emanuele Cozzani
- DISSAL Section of Dermatology, IRCCS Azienda Universitaria Ospedaliera San Martino-IST, Genoa, Italy
| | - Lee Haur Yueh
- Department of Dermatology, Singapore General Hospital, Singapore
| | - Giovanni Di Zenzo
- Laboratory of Molecular and Cell Biology, Istituto Dermopatico Dell’Immacolata, IDI-IRCCS, FLMM, Rome, Italy
| | - Yael Anne Leshem
- Department of Dermatology, Rabin Medical Center, Petah Tiqva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Mimouni
- Department of Dermatology, Rabin Medical Center, Petah Tiqva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael Hertl
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany
| | - Barbara Horvath
- Center for Blistering Diseases, Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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16
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Takemoto S, Ebara M, Hasebe S, Yakushijin Y. A study on the colonization of Pneumocystis jirovecii among outpatients during cancer chemotherapy and among healthy smokers. J Infect Chemother 2017; 23:752-756. [PMID: 28843641 DOI: 10.1016/j.jiac.2017.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/15/2017] [Accepted: 07/07/2017] [Indexed: 10/19/2022]
Abstract
AIMS Pneumocystis Jirovecii (PJ) is regarded as an agent of fungal infection and in cases of pneumocystis pneumonia (PCP) in immune-compromised patients including cancer patients. It is not clear what kinds of cancer, treatments, and environment need prophylaxis for PCP. In this study, we have analyzed the detectability of PJ DNA from sputum, and discussed prophylaxis and risk factors regarding PCP. METHODS A total of forty-nine materials (twenty-four from outpatients during cancer chemotherapies and twenty-five from healthy control subjects) was collected. Their PJ DNAs were amplified using nested PCR with specific primers of the PJ gene (the mitochondrial small subunit rRNA gene). RESULTS PJ DNA was detectable in 46% of specimens (sputum) from cancer patients during chemotherapies, and incidences of not significantly different among types of cancer and chemotherapy regimens. Prophylactic use of Sulfamethoxazole/Trimetoprim (ST) reduced the detection of PJ DNA. Detection of PJ DNA is not high among healthy non-smokers (20%) and high among healthy smokers (47%). CONCLUSIONS Prophylactic use of ST may be necessary for cancer patients during chemotherapies. Also, smoking may be associated with PJ colonization in the airway and air vesicles, and may increase the mortality rate for PCP. All patients undergoing cancer chemotherapies should cease smoking.
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Affiliation(s)
| | | | - Shinji Hasebe
- Department of Clinical Oncology, Ehime University Graduate School of Medicine, Japan
| | - Yoshihiro Yakushijin
- Department of Clinical Oncology, Ehime University Graduate School of Medicine, Japan.
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17
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Cotter TG, Gathaiya N, Catania J, Loftus EV, Tremaine WJ, Baddour LM, Harmsen WS, Zinsmeister AR, Sandborn WJ, Limper AH, Pardi DS. Low Risk of Pneumonia From Pneumocystis jirovecii Infection in Patients With Inflammatory Bowel Disease Receiving Immune Suppression. Clin Gastroenterol Hepatol 2017; 15:850-856. [PMID: 28013116 PMCID: PMC5440197 DOI: 10.1016/j.cgh.2016.11.037] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Revised: 10/23/2016] [Accepted: 11/29/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Use of immunosuppressants and inflammatory bowel disease (IBD) may increase the risk of pneumonia caused by Pneumocystis jirovecii (PJP). We assessed the risk of PJP in a population-based cohort of patients with IBD treated with corticosteroids, immune-suppressive medications, and biologics. METHODS We performed a population-based cohort study of residents of Olmsted County, Minnesota, diagnosed with Crohn's disease (n = 427) or ulcerative colitis (n = 510) from 1970 through 2011. Records of patients were reviewed to identify all episodes of immunosuppressive therapies and concomitant PJP prophylaxis through February 2016. We reviewed charts to identify cases of PJP, cross-referenced with the Rochester Epidemiology Project database (using diagnostic codes for PJP) and the Mayo Clinic and Olmsted Medical Center databases. The primary outcome was risk of PJP associated with the use of corticosteroids, immune-suppressive medications, and biologics by patients with IBD. RESULTS Our analysis included 937 patients and 6066 patient-years of follow-up evaluation (median, 14.8 y per patient). Medications used included corticosteroids (520 patients; 55.5%; 555.4 patient-years of exposure), immunosuppressants (304 patients; 32.4%; 1555.7 patient-years of exposure), and biologics (193 patients; 20.5%; 670 patient-years of exposure). Double therapy (corticosteroids and either immunosuppressants and biologics) was used by 236 patients (25.2%), with 173 patient-years of exposure. Triple therapy (corticosteroids, immunosuppressants, and biologics) was used by 70 patients (7.5%) with 18.9 patient-years of exposure. There were 3 cases of PJP, conferring a risk of 0.2 (95% CI, 0.01-1.0) to corticosteroids, 0.1 (95% CI, 0.02-0.5) cases per 100 patient-years of exposure to immunosuppressants, 0.3 (95% CI, 0.04-1.1) cases per 100 patient-years of exposure to biologics, 0.6 (95% CI, 0.01-3.2) cases per 100 patient-years of exposure to double therapy, and 0 (95% CI, 0.0-19.5) cases per 100 patient-years of exposure to triple therapy. Primary prophylaxis for PJP was prescribed to 37 patients, for a total of 24.9 patient-years of exposure. CONCLUSIONS In a population-based cohort of patients with IBD treated with corticosteroids, immunosuppressants, and biologics, there were only 3 cases of PJP, despite the uncommon use of PJP prophylaxis. Routine administration of PJP prophylaxis in these patients may not be warranted, although it should be considered for high-risk groups, such as patients receiving triple therapy.
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Affiliation(s)
- Thomas G Cotter
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Nicola Gathaiya
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jelena Catania
- Division of Infectious Disease, Mayo Clinic, Rochester, Minnesota
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - William J Tremaine
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Larry M Baddour
- Division of Infectious Disease, Mayo Clinic, Rochester, Minnesota
| | - W Scott Harmsen
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Alan R Zinsmeister
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Andrew H Limper
- Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, Minnesota
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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Prevention and management of glucocorticoid-induced side effects: A comprehensive review. J Am Acad Dermatol 2017; 76:191-198. [DOI: 10.1016/j.jaad.2016.02.1240] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 02/01/2016] [Indexed: 01/04/2023]
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19
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Is There a Role for Opportunistic Infection Prophylaxis in Pemphigus? An Expert Survey. Am J Clin Dermatol 2017; 18:127-132. [PMID: 27826815 DOI: 10.1007/s40257-016-0233-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Opportunistic infections (OIs) are a dreaded adverse effect of immunosuppressive therapy, leading to the use of opportunistic infection prophylaxis (OIP) in many immunosuppressed conditions. However, guidelines for OIP in pemphigus are lacking. OBJECTIVE Our objective was to evaluate the approach of leading pemphigus experts towards OIP. METHODS We conducted an online survey of OIP trends. RESULTS The survey was completed by 33 experts. Prior to initiation of immunosuppressive therapy, 75% routinely screened for hepatitis viruses, and at least half screened for HIV or tuberculosis. Most experts (76%) prescribed OIP but to <10% of their patients, and the most frequent drugs of choice were sulfamethoxazole/trimethoprim and acyclovir. Most experts agreed that treatment with three or more immunosuppressive agents or a previous history of OIs would lead to the use of OIP that was then discontinued with cessation of immunosuppression. The arguments against OIP were the lack of evidence for its necessity and concern about side effects or emergence of resistant pathogens. The surveyed experts treated patients with severe disease in a tertiary care setting, which may have led to an overestimation of the use of OIP. Infectious disease specialists were not included. CONCLUSION Substantial disparities exist in approaches to OIP for patients with pemphigus, including the decision to treat, type of treatment, and risk stratification among pemphigus experts.
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Amber KT. Balancing the risks and benefits of prophylaxis: a reply to “Pneumocystis jirovecipneumonia in patients treated with systemic immunosuppressive agents for dermatologic conditions”. Int J Dermatol 2016; 56:e4-e5. [DOI: 10.1111/ijd.13395] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 05/17/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Kyle T. Amber
- Department of Dermatology; University of California Irvine; Irvine CA USA
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21
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Podlipnik S, de la Mora L, Alsina M, Mascaró JM. Pneumocystis jirovecii pneumonia in a patient with pustular psoriasis with an IL-36RN deficiency treated with infliximab: Case report and review of the literature. Australas J Dermatol 2016; 58:e44-e47. [PMID: 27170513 DOI: 10.1111/ajd.12489] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 03/11/2016] [Indexed: 12/01/2022]
Abstract
Pneumocystis jirovecii pneumonia (PCP) is a relatively rare complication in non-HIV patients receiving immunosuppressive treatment. Since the introduction of tumour necrosis factor-α inhibitors cases of this complication have increased. We report the case of a 54-year-old, HIV-negative patient, who presented to our department with a long history of pustular psoriasis with poor response to traditional treatments. During the last admission he developed a severe flare that was unresponsive to cyclosporine, therefore infliximab was initiated. After the third dose he developed PCP that required admission to the intensive care unit, with a positive response to i.v. administration of trimethoprim/sulfamethoxazole. During follow up a mutation in the IL36RN gene compatible with an IL-36RN deficiency was found and anakinra was started, with rapid improvement of his psoriasis. PCP is a severe complication in patients receiving immunosuppressive therapy and is probably underreported by dermatologists. There are no clinical guidelines for PCP prophylaxis in dermatological patients who will receive immunosuppressive or biological treatments. We believe that it is necessary to report the cases of PCP to assess the real impact of this complication and develop appropriate prophylaxis guidelines.
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Affiliation(s)
- Sebastian Podlipnik
- Department of Dermatology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Lorena de la Mora
- Department of Internal Medicine, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Mercè Alsina
- Department of Dermatology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - José M Mascaró
- Department of Dermatology, Hospital Clinic, University of Barcelona, Barcelona, Spain
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22
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Gonzalez Santiago TM, Wetter DA, Kalaaji AN, Limper AH, Lehman JS. Pneumocystis jiroveci pneumonia in patients treated with systemic immunosuppressive agents for dermatologic conditions: a systematic review with recommendations for prophylaxis. Int J Dermatol 2016; 55:823-30. [PMID: 27009930 DOI: 10.1111/ijd.13231] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 10/29/2015] [Accepted: 11/04/2015] [Indexed: 11/29/2022]
Abstract
Pneumocystis jiroveci pneumonia is an opportunistic infection associated with substantial rates of mortality in immunosuppressed patients. Prophylaxis recommendations are mostly targeted toward patients with non-dermatologic diagnoses. This study was conducted to determine when dermatology patients treated with immunosuppressive medications should be offered P. jiroveci pneumonia prophylaxis. We searched the literature from January 1, 1993, to December 31, 2013, using terms relating to P. jiroveci pneumonia and dermatologic diagnoses to analyze the clinical characteristics of previously affected patients. Guidelines for P. jiroveci pneumonia prophylaxis from other medical fields were also analyzed. Of 17 dermatology patients reported to have contracted P. jiroveci pneumonia, eight (47.1%) died of the pneumonia. Risk factors included lack of prophylaxis, systemic corticosteroid therapy, lymphopenia, hypoalbuminemia, low serum CD4 counts, comorbid pulmonary or renal disease, malignancy, and prior organ transplantation. The present conclusions are limited by heterogeneity among the selected studies and limitations in their identification and selection. However, P. jiroveci pneumonia in dermatology patients is associated with a high mortality rate. Based on our analysis, we propose that prophylaxis be considered in dermatology patients in whom treatment with systemic corticosteroids at doses exceeding 20 mg/day or treatment with corticosteroid-sparing immunosuppressive agents is anticipated for at least 4 weeks, and in patients with additional risk factors for P. jiroveci pneumonia.
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Affiliation(s)
| | - David A Wetter
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Amer N Kalaaji
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Andrew H Limper
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | - Julia S Lehman
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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Lehman JS, Wetter DA, Davis MD, el-Azhary RA, Gibson LE, Kalaaji AN. Anticipating and preventing infection in patients treated with immunosuppressive medications for dermatologic indications: A dermatologist's checklist. J Am Acad Dermatol 2014; 71:e125-6. [DOI: 10.1016/j.jaad.2014.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 03/05/2014] [Accepted: 03/11/2014] [Indexed: 11/24/2022]
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Opportunistic infections in patients with pemphigus. J Am Acad Dermatol 2014; 71:284-92. [DOI: 10.1016/j.jaad.2014.03.020] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 03/12/2014] [Accepted: 03/16/2014] [Indexed: 11/19/2022]
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Lehman JS, Khunger M, Lohse CM. Infection in autoimmune bullous diseases: A retrospective comparative study. J Dermatol 2013; 40:613-9. [DOI: 10.1111/1346-8138.12175] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 03/21/2013] [Indexed: 12/27/2022]
Affiliation(s)
- Julia S. Lehman
- Division of Dermatopathology and Cutaneous Immunopathology; Department of Dermatology; Mayo Clinic; Rochester; Minnesota; USA
| | - Monica Khunger
- All India Institute of Medical Sciences; New Delhi; India
| | - Christine M. Lohse
- Division of Biomedical Statistics and Informatics; Mayo Clinic; Rochester; Minnesota; USA
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Lehman JS, Murrell DF, Camilleri MJ, Kalaaji AN. Infection and Infection Prevention in Patients Treated with Immunosuppressive Medications for Autoimmune Bullous Disorders. Dermatol Clin 2011; 29:591-8. [DOI: 10.1016/j.det.2011.06.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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