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Hung M, Huang DF, Chen WS, Lai CC, Chen MH, Liao HT, Tsai CY. The clinical features and mortality risk factors of cytomegalovirus infection in patients with systemic lupus erythematosus. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2018; 52:114-121. [PMID: 30598425 DOI: 10.1016/j.jmii.2018.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 11/27/2018] [Accepted: 12/07/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND The clinical features and outcomes of cytomegalovirus (CMV) diseases in patients with systemic lupus erythematosus (SLE) are unknown. We analyzed such data from a medical center in Taiwan. METHODS We retrospectively reviewed the medical records of patients with SLE who were diagnosed with CMV diseases between 2006 and 2016 in Taipei Veterans General Hospital Taiwan. Clinical and laboratory parameters and treatment outcomes were analyzed. RESULTS The study enrolled 56 eligible patients with CMV diseases and separated them into survival (n = 24) and mortality (n = 32) groups. All cases showed a significantly high incidence of pneumonitis (71.43%). The patients in the mortality group had a higher SLE disease activity index (SLEDAI)-2000 (p = 0.009), more cases of recent methylprednisolone pulse therapy (p = 0.013) and pancytopenia (p = 0.001), stronger evidence of CMV infection demonstrated by polymerase chain reaction (PCR) in blood (p < 0.001) and bronchoalveolar lavage (p = 0.021), and more concurrent infections (bacteremia p = 0.026; fungemia p < 0.001). CONCLUSIONS Recent pulse therapy, pancytopenia, and concurrent infections constituted risk factors for mortality in patients with SLE and CMV infection. Among mortality patients, PCR rather than serological tests (IgM antibodies) helped to arrive at an earlier diagnosis.
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Affiliation(s)
| | - Deh-Feng Huang
- Division of Allergy, Immunology, & Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wei-Sheng Chen
- Division of Allergy, Immunology, & Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; National Yang-Ming University Faculty of Medicine, Taipei, Taiwan
| | - Chien-Chih Lai
- Division of Allergy, Immunology, & Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; National Yang-Ming University Faculty of Medicine, Taipei, Taiwan
| | - Ming-Han Chen
- Division of Allergy, Immunology, & Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; National Yang-Ming University Faculty of Medicine, Taipei, Taiwan
| | - Hsien-Tzung Liao
- Division of Allergy, Immunology, & Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chang-Youh Tsai
- Division of Allergy, Immunology, & Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; National Yang-Ming University Faculty of Medicine, Taipei, Taiwan.
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Abstract
PURPOSE To describe the clinical characteristics, diagnosis, and treatment of VIAU in immunocompromised patients. METHODS A critical review of literature was performed. RESULTS Diagnosis and treatment of VIAU in immunocompromised patients may be a challenge due to atypical clinical-courses, severe presentations, and more frequent recurrences. A conclusive diagnosis can be made by aqueous-humour PCR-analysis. Visual prognosis depends on early diagnosis and prompt treatment. Frequent ocular examinations are recommended in HIV patients with CD-4-counts below 100 in order to rule out opportunistic ocular coinfections. It is essential to bear in mind the potential side-effects of therapeutic interventions and consider the possibility of Immune Recovery Uveitis (IRU) in eyes with treated viral retinitis after the initiation of HAART. CONCLUSIONS Early diagnosis and treatment of VIAU in immunocompromised patients can be achieved with high suspicion, recognizing clinical features, and obtaining specimens for molecular diagnostic testing in order to avoid usually severe ocular morbidity.
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Affiliation(s)
- Alejandra de-la-Torre
- a Grupo de Investigación en Neurociencias (NeURos), Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario , Bogotá , Colombia
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Yanagisawa K, Ogawa Y, Hosogai M, Todokoro D, Mitsui T, Yokohama A, Kishi S, Handa H. Cytomegalovirus retinitis followed by immune recovery uveitis in an elderly patient with rheumatoid arthritis undergoing administration of methotrexate and tofacitinib combination therapy. J Infect Chemother 2017; 23:572-575. [DOI: 10.1016/j.jiac.2017.03.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 02/21/2017] [Accepted: 03/07/2017] [Indexed: 11/28/2022]
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Xue Y, Jiang L, Wan WG, Chen YM, Zhang J, Zhang ZC. Cytomegalovirus Pneumonia in Patients with Rheumatic Diseases After Immunosuppressive Therapy: A Single Center Study in China. Chin Med J (Engl) 2017; 129:267-73. [PMID: 26831226 PMCID: PMC4799568 DOI: 10.4103/0366-6999.174490] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Rheumatic diseases involve multiple organs that are affected by immunological mechanisms. Treatment with corticosteroids and immunosuppressive agents may also increase the frequency of infection. Cytomegalovirus (CMV) is a widespread herpes virus and a well-recognized pathogen, which causes an opportunistic and potentially fatal infection in immunocompromised patients. This retrospective study aimed to investigate the clinical and laboratory characteristics of CMV pneumonia in patients with rheumatic diseases after immunosuppressive therapy in a single center in Shanghai, China. Methods: Eight hundred and thirty-four patients with rheumatic diseases who had undergone CMV-DNA viral load tests were included, and the medical records of 142 patients who were positive for CMV-DNA in plasma samples were evaluated. GraphPad Prism version 5.013 (San Diego, CA, USA) was used to conduct statistical analysis. The correlation between CMV-DNA viral loads and lymphocyte counts was assessed using the Spearman rank correlation coefficient test. Significance between qualitative data was analyzed using Pearson's Chi-squared test. The cut-off thresholds for CMV-DNA viral load and lymphocyte count were determined by receiver operating characteristic (ROC) curve analysis. Results: One hundred and forty-two patients had positive CMV viral load tests. Of these 142 patients, 73 patients with CMV pneumonia were regarded as symptomatic, and the other 69 were asymptomatic. The symptomatic group received higher doses of prednisolone (PSL) and more frequently immunosuppressants than the asymptomatic group (P < 0.01). The symptomatic group had lower lymphocyte counts, especially CD4+ T-cells, than the asymptomatic group (P < 0.01). By ROC curve analysis, when CD4+ T-cell count was <0.39 × 109/L, patients with rheumatic diseases were at high risk for symptomatic CMV infection. The CMV-DNA load was significantly higher in the symptomatic patients than that in asymptomatic patients (P < 0.01; threshold viral loads: 1.75 × 104 copies/ml). Seven patients had a fatal outcome, and they had lower peripheral lymphocyte counts (P < 0.01), including CD4+ and CD8+ T-cells (P < 0.01). Conclusions: When CD4+ T-cell count is <0.39 × 109/L, patients are at high risk for pulmonary CMV infection. Patients are prone to be symptomatic with CMV-DNA load >1.75 × 104 copies/ml. Lymphopenia (especially CD4+ T-cells), presence of symptoms, and other infections, especially fungal infection, are significant risk factors for poor outcome, and a higher PSL dosage combined with immunosuppressants may predict CMV pneumonia.
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Affiliation(s)
| | | | | | | | | | - Zhen-Chun Zhang
- Institute of Rheumatology, Immunology and Allergy, Fudan University, Shanghai 200040; Department of Rheumatology, Linyi People's Hospital, Linyi, Shandong 276000, China
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Tsai WP, Chen MH, Lee MH, Yu KH, Wu MW, Liou LB. Cytomegalovirus infection causes morbidity and mortality in patients with autoimmune diseases, particularly systemic lupus: in a Chinese population in Taiwan. Rheumatol Int 2011; 32:2901-8. [PMID: 21898057 DOI: 10.1007/s00296-011-2131-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2011] [Accepted: 08/22/2011] [Indexed: 11/26/2022]
Abstract
To investigate the clinical outcome of cytomegalovirus (CMV) infection in febrile hospitalized patients with autoimmune diseases, mostly systemic lupus erythematosus (SLE). Fifty-four febrile patients were analyzed retrospectively. Half were diagnosed as CMV infection, by positive CMV pp65 antigenemia assay. Clinical and laboratory data between two groups were compared. Correlation between laboratory data and SELENA-SLEDAI scores/mortality were analyzed in the CMV infection group. Receiver operating characteristic analysis was performed to determine the cutoff points of different parameters for predicting mortality or morbidity. The CMV infection group received a higher corticosteroid dosage (mean 26.3 mg/day) and a higher percentage of azathioprine use before admission than the non-CMV infection group. In the former, the deceased subgroup had a significantly higher number of infected leukocytes for CMV (shortened as CMV counts, P = 0.013), more cases of bacterial infection (P = 0.090), and a higher SLE disease activity index score (P = 0.072) than the alive subgroup. The CMV infection group had lower lymphocyte count and more positive bacterial infection than the non-CMV infection group did (P = 0.013 and P = 0.027, respectively). A level of 25 CMV particles/5 × 10(5) polymorphonuclear neutrophils (PMN) was the best cutoff point for predicting CMV-associated mortality, with a sensitivity of 75.0% and specificity of 72.2%. Moderate dose (30 mg/day) of prednisolone or azathioprine use predisposes patients with autoimmune diseases to CMV infection with concurrent bacterial infection. In particular, peak CMV counts at 25/5 × 10(5) PMN or low lymphocyte counts predict mortality or morbidity, respectively.
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Affiliation(s)
- W P Tsai
- Chang Gung Memorial Hospital, Lin-kou, Tao-yuan, Taiwan
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Takizawa Y, Inokuma S, Tanaka Y, Saito K, Atsumi T, Hirakata M, Kameda H, Hirohata S, Kondo H, Kumagai S, Tanaka Y. Clinical characteristics of cytomegalovirus infection in rheumatic diseases: multicentre survey in a large patient population. Rheumatology (Oxford) 2008; 47:1373-8. [PMID: 18577548 DOI: 10.1093/rheumatology/ken231] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To survey and elucidate the clinical characteristics of CMV infection in rheumatic disease patients. METHODS A detailed questionnaire survey on CMV infection was carried out against rheumatic disease patients hospitalized in member hospitals, and the obtained clinical and/or laboratory data were analysed. RESULTS Out of 7377 patients, 151 were diagnosed as having CMV infection. The underlying diseases ranged broadly, but SLE, microscopic polyangiitis, and dermatomyositis were the most common. Four were diagnosed histopathologically, and the others via positive CMV antigenaemia. In addition to oral corticosteroid for all but one patient, 81 were treated with pulsed methylprednisolone (MPSL), 64 with cyclophosphamide (CYC) and 36 with other immunosuppressants. Forty-four had a fatal outcome, for which presence of clinical symptoms, other infectious complications, lymphopenia, an older age (>59.3 yrs) and the use of pulsed MPSL were significant risk factors (P < 0.05) by univariate analysis. Multivariate analysis retained the first three (P < 0.05). The CMV antigenaemia count was significantly higher for the symptomatic than asymptomatic [10.1 (0.0-2998.0) vs 4.0 (1.3-1144.4)/10(5) PMNs, respectively, P < 0.05; threshold count: 5.6/10(5) PMNs]. No treatment benefit by anti-viral agent was observed as for survival. CONCLUSION CMV infection was mostly diagnosed by antigenaemia, and occurred among patients under strong immunosuppressive therapy using pulsed MPSL and/or immunosuppressants. Lymphopenia, presence of symptoms and other infections are significant risk factors for a poor outcome and pulsed MPSL and an older age may predict it. Patients were prone to be symptomatic with anti-genaemia count over 5.6/10(5) PMNs.
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Affiliation(s)
- Y Takizawa
- Department of Allergy and Immunological Diseases, Tokyo Metropolitan Komagome Hospital, Bunkyo-ku, 3-18-22 Honkomagome, Tokyo 113-8677, Japan.
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Kim HR, Kim SD, Kim SH, Yoon CH, Lee SH, Park SH, Kim HY. Cytomegalovirus retinitis in a patient with dermatomyositis. Clin Rheumatol 2006; 26:801-3. [PMID: 16552465 DOI: 10.1007/s10067-006-0239-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2005] [Accepted: 09/09/2005] [Indexed: 10/24/2022]
Abstract
Cytomegalovirus (CMV) retinitis rarely occurs in patients with connective tissue disease. We present a rare case of CMV retinitis in a patient with dermatomyositis. A 38-year-old man was admitted due to blurred vision and floaters of right eye. He had been diagnosed with dermatomyositis and taken prednisolone and immunosuppressive agents for 10 months. He was diagnosed as having CMV retinitis based upon ophthalmologic examination, decreased CD4+T cell count, and positive IgM anti-CMV antibody. Intravenous ganciclovir was administrated with cessation of immunosuppressive agents for 40 days and the lesion did not progress. This is the first report of a CMV retinitis that developed in a patient with dermatomyositis.
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Affiliation(s)
- Hae-Rim Kim
- Department of Internal Medicine, School of Medicine, Konkuk University, 4-12 Hwayang-dong, Gwangjin-gu, Seoul 143-729, South Korea
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Bertelmann E, Liekfeld A, Pleyer U, Hartmann C. Cytomegalovirus retinitis in Wegener's granulomatosis: case report and review of the literature. ACTA ACUST UNITED AC 2005; 83:258-61. [PMID: 15799746 DOI: 10.1111/j.1600-0420.2005.00410.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To present the first case of cytomegalovirus (CMV) retinitis in a Wegener's granulomatosis patient on systemic cyclosporine A (CsA) therapy. METHODS A 41-year-old patient was treated with systemic CsA for c-ANCA positive Wegener's granulomatosis. Four weeks later he presented with blurred vision and a retinitis was diagnosed in the right eye. After detection of CMV DNA by polymerase chain reaction (PCR), the patient was treated with intravenous gancyclovir. Due to bone marrow toxicity, systemic antiviral therapy was discontinued and an intravitreal gancyclovir pellet was implanted. RESULTS The retinitis lesions were scarified under this therapy and the patient's visual function was restored completely. CONCLUSIONS Cytomegalovirus retinitis can occur under systemic monotherapy with CsA in patients with systemic vasculitis. Intraocular virus DNA detection by PCR is recommended to rule out retinal involvement of the underlying vasculitis in atypical cases and to preserve the patient's visual acuity.
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Affiliation(s)
- Eckart Bertelmann
- Clinic of Ophthalmology, Charité- University School of Medicine Berlin, Berlin, Germany.
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Shahnaz S, Choksi MT, Tan IJ. Bilateral cytomegalovirus retinitis in a patient with systemic lupus erythematosus and end-stage renal disease. Mayo Clin Proc 2003; 78:1412-5. [PMID: 14601702 DOI: 10.4065/78.11.1412] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Rheumatic diseases are not commonly associated with cytomegalovirus (CMV) retinitis. We report a case of bilateral CMV retinitis in a human immunodeficiency virus-seronegative patient with systemic lupus erythematosus (SLE) who was undergoing hemodialysis for end-stage renal disease. The CMV retinitis in this patient was associated with combined azathioprine and low-dose corticosteroid therapy for lupus flare. This association may have important clinical implications because this drug combination is used routinely to treat active SLE. Our patient responded to discontinuation of azathioprine, reduction of the corticosteroid dose, and systemic administration of ganciclovir. We recommend that clinicians maintain heightened awareness of the possibility of CMV retinitis in patients with SLE and end-stage renal disease who are receiving azathioprine and low-dose corticosteroids.
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Affiliation(s)
- Sabiha Shahnaz
- Department of Medicine, Mount Sinai Services at Queens Hospital Center, Jamaica, NY 11432, USA
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Abstract
Background. - Pulmonary dysfunction in rheumatoid arthritis (RA) patients treated with low-dose methotrexate is usually caused by bacterial infection and less frequently by an immunoallergic reaction to the drug (acute hypersensitivity pneumonitis). Opportunistic infections are a rare cause. We report a case of cytomegalovirus pneumonia during bone marrow aplasia in a patient with RA taking methotrexate and cyclosporine.Conclusions. - Cytomegalovirus infection is a rarely reported cause of pulmonary dysfunction. This diagnosis should be considered in immunocompromised RA patients with no other satisfactory explanation for pulmonary dysfunction.
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Affiliation(s)
- Véronique Belin
- Rheumatology Department, Lyon South Hospital Center, Lyon, France
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Martínez Cristóbal A, Juanola Roura X, Poca Días V, Ordóñez Palau S. [Gastric ulcer caused by cytomegalovirus in a patient with rheumatoid arthritis]. Rev Clin Esp 2001; 201:362. [PMID: 11490918 DOI: 10.1016/s0014-2565(01)70846-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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