1
|
Abdel-Magied RA, Mokhtar NW, Abdullah NM, Abdel-Naiem ASM. Infection versus disease activity in systemic lupus erythematosus patients with fever. BMC Rheumatol 2024; 8:34. [PMID: 39143483 DOI: 10.1186/s41927-024-00395-6] [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: 12/21/2023] [Accepted: 06/03/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND to detect the role of procalcitonin, erythrocyte sedimentation rate to c-reactive protein (ESR/CRP) ratio, neutrophils-to-lymphocyte ratio (NLR), and platelets-to-lymphocyte ratio (PLR) in the diagnosis of infection in systemic lupus erythematosus (SLE) patients with fever, their diagnostic value to differentiate between infection and disease activity, and their correlation with disease activity. METHODS Forty SLE patients and forty healthy control cases were included in the study. Disease activity was assessed by the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2 K), and quality of life was assessed by Lupus QoL. A bacterial infection was detected by clinical symptoms and positive culture results. Laboratory tests were done for all patients and controls: complete blood count (CBC), ESR, CRP, and procalcitonin (PCT). NLR, PLR, and ESR/CRP ratios were calculated. RESULTS There was a statistically significant difference between infected SLE patients and non-infected SLE patients regarding PCT (p < 0.001), ESR (p = 0.002), CRP (p = 0.005), ESR/CRP ratio (0.002), and NLR (p = 0.023). PCT, ESR, CRP, and NLR were positively correlated with the presence of infection in SLE patients, while the ESR/CRP ratio was negatively correlated. There was no significant correlation with the SLEDAI-2 K score. Logistic regression analysis revealed that PCT was the best significant predictor of infection (OR 224.37, 95% CI 8.94-5631.35). PCT was a good predictor of infection, with a cut-off value of 0.90 ng/ml, which gave the best combination of sensitivity (84.62%) and specificity (85.71%). CONCLUSION PCT, ESR/CRP ratio, and NLR provide good diagnostic markers for the diagnosis of infection and can distinguish between infection and disease flare in SLE patients with fever.
Collapse
Affiliation(s)
- Rasha A Abdel-Magied
- Rheumatology, Rehabilitation and Physical Medicine Department, Minia University, Minia, Egypt
| | - Nehal W Mokhtar
- Rheumatology, Rehabilitation and Physical Medicine Department, Minia University, Minia, Egypt
| | - Noha M Abdullah
- Clinical Pathology Departement, Minia University, Minia, Egypt.
| | | |
Collapse
|
2
|
Zhang S, Qiu Q, Zeng S, Li H, Xu L, Jie L, Hu X, Xiao Y, Chen D, Zhan Z, Liang L, Yu Q, Xu H. Response to belimumab among patients with refractory lupus nephritis: a real-world observational retrospective multicenter study. Clin Rheumatol 2024; 43:199-208. [PMID: 37982925 DOI: 10.1007/s10067-023-06817-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 08/22/2023] [Accepted: 11/11/2023] [Indexed: 11/21/2023]
Abstract
OBJECTIVES Belimumab is a biological agent approved for the treatment of active lupus nephritis (LN), but its efficacy on refractory lupus nephritis (LN) is unknown. This study aims to evaluate the efficacy and safety of belimumab in Chinese patients with refractory LN. METHODS This multicenter, observational, and retrospective study enrolled patients with refractory LN who failed induction therapy with steroids, cyclophosphamide, mycophenolate, and calcineurin inhibitors and received 24-week belimumab treatment before data analysis. Treatment outcomes include the overall clinical response (physician judgment, disease activity, organ damage) and renal response (complete renal response, partial renal response, no renal response). Laboratory indices and adverse events were recorded as well. RESULTS Of the 45 patients enrolled in the study, 6 (13.3%) achieved complete renal response, 19 (42.2%) achieved partial renal response, and the overall renal response rate was 55.6%. Median rSLEDAI decreased from 12 (IQR 8-12) at baseline to 8 (IQR 4-8) (p < 0.0001), 4 (IQR 4-8) (p < 0.0001) at 12 and 24 weeks. Mean urinary protein decreased more than 50% from 3.2 g/24 h at baseline to 1.0 g/24 h at 24 weeks (p < 0.0001). The conditions of hypoalbuminemia and hypocomplementemia had also gradually improved. The levels of autoantibodies showed a significant downward trend. Additionally, 9 (20.0%) patients successfully reduced the dosage of prednisone to a safe range, and 3 of them achieved their treatment goal of prednisone cessation. The mean prednisone dosage decreased from 32.7 mg/day at baseline to 18.6 mg/day (p < 0.0001), 13.3 mg/day (p < 0.0001) at 12 and 24 weeks. There were 3 adverse events reported, including 2 cases of infection, and 1 case of allergy. No serious events occurred during the follow-up. CONCLUSIONS Belimumab is effective and safe when used in clinical practice, which can be considered as an add-on therapy for refractory LN. Key Points • A multicenter observational study in the real clinical settings of China. • First revealed the efficacy and safety of belimumab in Chinese patients with refractory LN.
Collapse
Affiliation(s)
- Shuoyang Zhang
- Department of Rheumatology and Immunology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Qian Qiu
- Department of Rheumatology and Immunology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Shan Zeng
- Department of Rheumatology, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Hao Li
- Department of Rheumatology and Immunology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Liujing Xu
- Department of Rheumatology and Immunology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Ligang Jie
- Department of Rheumatology and Clinical Immunology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Xuejun Hu
- Department of Rheumatology, The First Peoples' Hospital of Zhaoqing, Zhaoqing, Guangdong, China
| | - Youjun Xiao
- Department of Rheumatology and Immunology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Dongying Chen
- Department of Rheumatology and Immunology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Zhongping Zhan
- Department of Rheumatology and Immunology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Liuqin Liang
- Department of Rheumatology and Immunology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China.
| | - Qinghong Yu
- Department of Rheumatology and Clinical Immunology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China.
| | - Hanshi Xu
- Department of Rheumatology and Immunology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China.
| |
Collapse
|
3
|
Zhang S, Zheng R, Pan Y, Sun H. Potential Therapeutic Value of the STING Inhibitors. Molecules 2023; 28:3127. [PMID: 37049889 PMCID: PMC10096477 DOI: 10.3390/molecules28073127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/22/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023] Open
Abstract
The stimulator of interferon genes (STING) is a critical protein in the activation of the immune system in response to DNA. It can participate the inflammatory response process by modulating the inflammation-preferred translation program through the STING-PKR-like endoplasmic reticulum kinase (PERK)-eIF2α pathway or by inducing the secretion of type I interferons (IFNs) and a variety of proinflammatory factors through the recruitment of TANK-binding kinase 1 (TBK1) and interferon regulatory factor 3 (IRF3) or the regulation of the nuclear factor kappa-B (NF-κB) pathway. Based on the structure, location, function, genotype, and regulatory mechanism of STING, this review summarizes the potential value of STING inhibitors in the prevention and treatment of infectious diseases, psoriasis, systemic lupus erythematosus, non-alcoholic fatty liver disease, and other inflammatory and autoimmune diseases.
Collapse
Affiliation(s)
- Shangran Zhang
- Jiangsu Key Laboratory of Drug Discovery for Metabolic Disease, State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing 210009, China
| | - Runan Zheng
- Jiangsu Key Laboratory of Drug Discovery for Metabolic Disease, State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing 210009, China
| | - Yanhong Pan
- Jiangsu Key Laboratory of Drug Discovery for Metabolic Disease, State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing 210009, China
- Department of Pharmacy, The Second Affiliated Hospital of Nanjing Medical University, Nanjing 210009, China
| | - Hongbin Sun
- Jiangsu Key Laboratory of Drug Discovery for Metabolic Disease, State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing 210009, China
- Chongqing Innovation Institute of China Pharmaceutical University, Chongqing 401135, China
| |
Collapse
|
4
|
Al-arbi KMS, Magula NP, Mody GM. Tuberculosis remains a major burden in systemic lupus erythematosus patients in Durban, South Africa. Front Med (Lausanne) 2023; 10:1118390. [PMID: 36936236 PMCID: PMC10014752 DOI: 10.3389/fmed.2023.1118390] [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: 12/07/2022] [Accepted: 02/07/2023] [Indexed: 03/05/2023] Open
Abstract
Objective Infections are common in systemic lupus erythematosus (SLE), with tuberculosis (TB) being important in an endemic environment. We studied the prevalence and spectrum of TB in SLE in Durban, South Africa. Methods A medical records review of SLE patients seen over 13-year period, and the demographic data, clinical manifestations, laboratory findings, treatment and outcome were noted. Results There were 512 SLE patients and 72 (14.1%) had TB. Thirty (41.7%) had pulmonary TB (PTB) and 42 (58.3%) had extra-pulmonary TB (EPTB). The prevalence of TB among the different ethnic groups was 36/282 (12.8%) for Indian people, 29/184 (15.8%) Black African people, 7/26 (26.9%) admixed African people and none among the 18 White people. Comparison of the 72 SLE-TB patients with 72 SLE controls showed no difference in gender, age at SLE diagnosis and disease duration. The SLE-TB patients had a significant increase in the clinical and laboratory features of disease activity (arthritis, mucocutaneous lesions, renal involvement, vasculitis, low complement, raised ds-DNA antibodies), and cumulative prednisone use over the preceding 3 months.Compared to PTB, the EPTB patients were significantly younger, developed TB earlier after SLE diagnosis, and had higher disease activity. The EPTB patients also had increase in features of disease activity (renal, thrombocytopenia, ds-DNA antibodies), and increase in ever use of intravenous methylprednisolone (IV-MP) and mycophenolate mofetil (MMF). On multivariate analysis, the independent risk factors for EPTB were ever use of MMF (p = 0.003) and IV-MP (p = 0.027). Analysis of the cumulative SLE criteria showed renal involvement was an independent risk factor for EPTB. The outcome was similar in both groups. Conclusion We show an increased prevalence of TB (14.1%) and EPTB (58.3%) in SLE in an endemic area and confirm that features of disease activity and use of immunosuppressive therapy are the major risk factors. Renal involvement (as a cumulative criterion) is an independent risk factor for EPTB.
Collapse
Affiliation(s)
- Khaled Mohamed Sefow Al-arbi
- Department of Rheumatology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal and Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Nombulelo P. Magula
- Division of Internal Medicine, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Girish M. Mody
- Department of Rheumatology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal and Inkosi Albert Luthuli Central Hospital, Durban, South Africa
- *Correspondence: Girish M. Mody,
| |
Collapse
|
5
|
Zhang W, Huang G, Lin J, Lin Q, Zheng K, Hu S, Zheng S, Du G, Matucci-Cerinic M, Furst DE, Wang Y. Predictive model of risk and severity of enteritis in systemic lupus erythematosus. Lupus 2022; 31:1226-1236. [PMID: 35750508 DOI: 10.1177/09612033221110743] [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: 11/15/2022]
Abstract
INTRODUCTION To describe the clinical and laboratory features of systemic lupus erythematosus (SLE) enteritis and to establish a predictive model of risk and severity of lupus enteritis (LE). METHODS Records of patients with SLE complaining about acute digestive symptoms were reviewed. The predictive nomogram for the diagnosis of LE was constructed by using R. The accuracy of the model was tested with correction curves. The receiver operating characteristic curve (ROC curve) program and a Decision curve analysis (DCA) were used for the verification of LE model. Receiver operating characteristic curve was also employed for evaluation of factors in the prediction of severity of LE. RESULTS During the eight year period, 46 patients were in the LE group, while 32 were in the non-LE group. Abdominal pain, emesis, D-dimer >5 μg/mL, hypo-C3, and anti-SSA positive remained statistically significant and were included into the prediction model. Area under the curve (AUC) of ROC curve in this model was 0.909. Correction curve indicated consistency between the predicted rate and actual diagnostic rates. The DCA showed that the LE model was of benefit. Forty-four patients were included in developing the prediction model of LE severity. Infection, SLE disease activity index (SLEDAI), CT score, and new CT score were validated as risk factors for LE severity. The AUC of the combined SLEDAI, infection and new CT score were 0.870. CONCLUSION The LE model exhibits good predictive ability to assess LE risk in SLE patients with acute digestive symptoms. The combination of SLEDAI, infection, and new CT score could improve the assessment of LE severity.
Collapse
Affiliation(s)
- Weijin Zhang
- Department of Rheumatology and Immunology, 499791Shantou Central Hospital, Shantou, China
| | - Guohai Huang
- Department of Blood Purification, 499791Shantou Central Hospital, Shantou, China
| | - Jianqun Lin
- Department of Rheumatology and Immunology, 499791Shantou Central Hospital, Shantou, China
| | - Qisheng Lin
- Department of Rheumatology and Immunology, 499791Shantou Central Hospital, Shantou, China
| | - Kedi Zheng
- Department of Rheumatology and Immunology, 499791Shantou Central Hospital, Shantou, China
| | - Shijian Hu
- Department of Rheumatology and Immunology, 499791Shantou Central Hospital, Shantou, China
| | - Shaoyu Zheng
- Department of Rheumatology and Immunology, 499791Shantou Central Hospital, Shantou, China
| | - Guangzhou Du
- Department of Radiology, 499791Shantou Central Hospital, Shantou, China
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, Division of Rheumatology, Careggi University Hospital, 9300University of Florence, Florence, Italy.,Unit of Immunology, Rheumatology, Allergy and Rare diseases (UnIRAR), IRCCS San Raffaele Hospital, Milan, Italy
| | - Daniel E Furst
- Department of Experimental and Clinical Medicine, Division of Rheumatology, Careggi University Hospital, 9300University of Florence, Florence, Italy.,Division of Rheumatology, Department of Medicine, 8783University of California at Los Angeles, USA.,University of Washington, Seattle, WA, USA
| | - Yukai Wang
- Department of Rheumatology and Immunology, 499791Shantou Central Hospital, Shantou, China.,Department of Experimental and Clinical Medicine, Division of Rheumatology, Careggi University Hospital, 9300University of Florence, Florence, Italy
| |
Collapse
|
6
|
Huang SF, Huang CC, Chou KT, Chan YJ, Yang YY, Wang FD. Chronic Pulmonary Aspergillosis: Disease Severity Using Image Analysis and Correlation with Systemic Proinflammation and Predictors of Clinical Outcome. J Fungi (Basel) 2021; 7:jof7100842. [PMID: 34682263 PMCID: PMC8537715 DOI: 10.3390/jof7100842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/02/2021] [Accepted: 10/03/2021] [Indexed: 02/07/2023] Open
Abstract
(1) Background: The presentation of chronic pulmonary aspergillosis (CPA) ranges from single granuloma to fibrosis in the affected lung. CPA can be divided into five categories according to European Respirology Society (ERS) guidance but is usually assessed by clinical physicians. Computer-based quantitative lung parenchyma analysis in CPA and its correlation with clinical manifestations, systemic inflammation, and angiogenesis have never been investigated. (2) Method: Forty-nine patients with CPA and 36 controls were prospectively enrolled. Pulmonary function tests (forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and FEV1/FCV) and biomarkers in the peripheral blood (the chemokines interleukin (IL)-1B, IL-6, IL-10, IL-8, CRP, ESR, MMP1, MMP7, MMP8, TNF-α, calprotectin, SDF-1α, and VEGFA) were measured before antifungal treatment. The disease severity was categorized into mild, moderate, and severe based on chest computed tomography (CT) images. The oxygen demand and overall mortality until the end of the study were recorded. Quantitative parenchyma analysis was performed using the free software 3Dslicer. (3) Results: The results of quantitative parenchyma analysis concorded with the visual severity from the chest CT, oxygen demand, FVC, and FEV1 in the study subjects. The decrease in kurtosis and skewness of the lung density histograms on CT, increase in high attenuation area (HAA), and reduced lung volume were significantly correlated with increases in the PMN %, CRP, IL-1B, SDF-1α, MMP1, and Calprotectin in peripheral blood in the multivariable regression analysis. TNF-α and IL-1B at study entry and the CPA severity from either a visual method or computer-based evaluation were predictors of long-term mortality. (4) Conclusion: The computer-based parenchyma analysis in CPA agreed with the categorization on a visual basis and was associated with the clinical outcomes, chemokines, and systemic proinflammation profiles.
Collapse
Affiliation(s)
- Shiang-Fen Huang
- Division of Infectious Disease, Department of Medicine, Taipei Veterans General Hospital, Taipei 112201, Taiwan;
- School of Medicine, National Yang-Ming Chiao-Tung University, Taipei 112304, Taiwan;
- Correspondence:
| | - Chia-Chang Huang
- Division of Endocrinology and Metabolism, Department of Medicine, Veterans General Hospital, Taipei 112201, Taiwan;
- Division of Clinical Skills Training, Department of Medical Education, Taipei Veterans General Hospital, Taipei 112201, Taiwan;
| | - Kun-Ta Chou
- School of Medicine, National Yang-Ming Chiao-Tung University, Taipei 112304, Taiwan;
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei 112201, Taiwan
| | - Yu-Jiun Chan
- Division of Microbiology, Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei 112201, Taiwan;
| | - Ying-Ying Yang
- Division of Clinical Skills Training, Department of Medical Education, Taipei Veterans General Hospital, Taipei 112201, Taiwan;
- Department of Medicine, Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei 112304, Taiwan
| | - Fu-Der Wang
- Division of Infectious Disease, Department of Medicine, Taipei Veterans General Hospital, Taipei 112201, Taiwan;
- School of Medicine, National Yang-Ming Chiao-Tung University, Taipei 112304, Taiwan;
| |
Collapse
|
7
|
Sari MK, Satria CD, Arguni E. Predictors of Infection in Children with Systemic Lupus Erythematosus: A Single Center Study in Indonesia. Glob Pediatr Health 2021; 8:2333794X211005609. [PMID: 33889678 PMCID: PMC8040617 DOI: 10.1177/2333794x211005609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/02/2021] [Indexed: 11/16/2022] Open
Abstract
Patients with Systemic Lupus Erythematosus (SLE) are susceptible to infection due to defects in their immune system. Corticosteroids and immunosuppressant drugs used as SLE therapy also contribute to infection. This study aimed is to determine predictors of infection in pediatric patients with SLE. This retrospective cohort study was conducted at Dr. Sardjito Hospital, a referral hospital in Yogyakarta, Indonesia between 2013 and 2019. Logistic regression analysis was performed to identify predictor variables for the occurrence of infection. A total of 109 SLE patients were included in this study. The incidence of infection in children with SLE was 27.5%. The most common types of infection in hospitalized SLE patients were urinary tract infections (41%), skin and soft tissue infections (20.5%), and pneumonia (20.5%). Multivariate regression analysis showed that the use of methylprednisolone pulse dose (RR 3.204; 95% CI 1.234-8.318) was a predictor of infection. Clinician should closely observe SLE patients with predictors for infection.
Collapse
Affiliation(s)
- Maria Kristianti Sari
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Cahya Dewi Satria
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Eggi Arguni
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| |
Collapse
|
8
|
Wang J, Liu J, Pan L, Guo L, Liu C, Yang S. Association between alcohol intake and the risk of systemic lupus erythematosus: A systematic review and meta-analysis. Lupus 2021; 30:725-733. [PMID: 33557684 DOI: 10.1177/0961203321991918] [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: 11/17/2022]
Abstract
OBJECTIVES Previous studies have reported inconsistent results on the relationship between alcohol intake and the risk of systemic lupus erythematosus (SLE). Therefore, we conducted a systematic review and meta-analysis to illustrate the potential role of alcohol intake on the progression of SLE. METHODS An electronic search of the PubMed, EmBase, and the Cochrane library databases was conducted from their inception up to March 2020. Observational studies that investigated the role of alcohol intake on the risk of SLE were eligible for inclusion in this study. The pooled odds ratio (OR) with 95% confidence interval (CI) was calculated as an effect estimate using the random-effects model. RESULTS Seven case-control studies (n = 3, 251) and three cohort studies (n = 322, 479) were selected for the final meta-analysis. Mild (OR: 0.85; 95% CI: 0.53-1.38; p = 0.515) or heavy (OR: 0.63; 95% CI: 0.37-1.09; p = 0.102) alcohol intake were not associated with the risk of SLE, while moderate alcohol intake could protect against the risk of SLE (OR: 0.71; 95% CI: 0.55-0.93; p = 0.012). Sensitivity analysis suggested that heavy alcohol intake was associated with a reduced risk of SLE (OR: 0.47; 95% CI: 0.32-0.67; p < 0.001). CONCLUSIONS This study found that moderate alcohol intake could protect against the risk of SLE, while mild or heavy alcohol intake did not significantly affect the risk of SLE.
Collapse
Affiliation(s)
- Jinghua Wang
- Department of Pediatric Rheumatology and Allergy, The First Hospital of Jilin University, Changchun, China
| | - Jinxiang Liu
- Department of Pediatric Rheumatology and Allergy, The First Hospital of Jilin University, Changchun, China
| | - Lu Pan
- Department of Pediatric Rheumatology and Allergy, The First Hospital of Jilin University, Changchun, China
| | - Lishuang Guo
- Department of Pediatric Rheumatology and Allergy, The First Hospital of Jilin University, Changchun, China
| | - Congcong Liu
- Department of Pediatric Rheumatology and Allergy, The First Hospital of Jilin University, Changchun, China
| | - Sirui Yang
- Department of Pediatric Rheumatology and Allergy, The First Hospital of Jilin University, Changchun, China
| |
Collapse
|
9
|
Restrepo-Escobar M, Granda-Carvajal PA, Aguirre DC, Hernández-Zapata J, Vásquez GM, Jaimes F. Predictive models of infection in patients with systemic lupus erythematosus: A systematic literature review. Lupus 2021; 30:421-430. [PMID: 33407048 DOI: 10.1177/0961203320983462] [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] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Having reliable predictive models of prognosis/the risk of infection in systemic lupus erythematosus (SLE) patients would allow this problem to be addressed on an individual basis to study and implement possible preventive or therapeutic interventions. OBJECTIVE To identify and analyze all predictive models of prognosis/the risk of infection in patients with SLE that exist in medical literature. METHODS A structured search in PubMed, Embase, and LILACS databases was carried out until May 9, 2020. In addition, a search for abstracts in the American Congress of Rheumatology (ACR) and European League Against Rheumatism (EULAR) annual meetings' archives published over the past eight years was also conducted. Studies on developing, validating or updating predictive prognostic models carried out in patients with SLE, in which the outcome to be predicted is some type of infection, that were generated in any clinical context and with any time horizon were included. There were no restrictions on language, date, or status of the publication. To carry out the systematic review, the CHARMS (Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies) guideline recommendations were followed. The PROBAST tool (A Tool to Assess the Risk of Bias and Applicability of Prediction Model Studies) was used to assess the risk of bias and the applicability of each model. RESULTS We identified four models of infection prognosis in patients with SLE. Mostly, there were very few events per candidate predictor. In addition, to construct the models, an initial selection was made based on univariate analyses with no contraction of the estimated coefficients being carried out. This suggests that the proposed models have a high probability of overfitting and being optimistic. CONCLUSIONS To date, very few prognostic models have been published on the infection of SLE patients. These models are very heterogeneous and are rated as having a high risk of bias and methodological weaknesses. Despite the widespread recognition of the frequency and severity of infections in SLE patients, there is no reliable predictive prognostic model that facilitates the study and implementation of personalized preventive or therapeutic measures.Protocol registration number: PROSPERO CRD42020171638.
Collapse
Affiliation(s)
| | - Paula A Granda-Carvajal
- Department of Internal Medicine and Subspecialties, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Daniel C Aguirre
- Medical Research Institute, Universidad de Antioquia, Medellín, Colombia
| | | | - Gloria M Vásquez
- Department of Internal Medicine, Universidad de Antioquia, Medellín, Colombia
| | - Fabián Jaimes
- Department of Internal Medicine, Universidad de Antioquia, Medellín, Colombia
| |
Collapse
|
10
|
Singh JA, Cleveland JD. Hospitalized Infections in Lupus: A Nationwide Study of Types of Infections, Time Trends, Health Care Utilization, and In-Hospital Mortality. Arthritis Rheumatol 2020; 73:617-630. [PMID: 33142044 DOI: 10.1002/art.41577] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 10/29/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To examine the time trends in hospitalized infections in patients with systemic lupus erythematosus (SLE), and the factors associated with health care utilization and in-hospital mortality. METHODS US National Inpatient Sample data from 1998-2016 were used to examine the epidemiology, time trends, and outcomes of 5 common hospitalized infections in patients with SLE, namely, pneumonia, sepsis/bacteremia, urinary tract infection (UTI), skin and soft tissue infections (SSTIs), and opportunistic infections (OIs). Time trends were compared using the Cochran-Armitage test. Multivariable-adjusted logistic regression models were used to examine the factors associated with health care utilization (hospital stay >3 days, hospital charges above the median, or discharge to a nonhome setting) and in-hospital mortality. RESULTS Hospitalization rates per 100,000 claims among SLE patients in 1998-2000 versus in 2015-2016 were as follows: for OIs, 1.13 versus 1.61 (1.2-fold increase); for SSTIs, 4.78 versus 12.2 (2.5-fold increase); for UTI, 1.94 versus 6.12 (3.2-fold increase); for pneumonia, 15.09 versus 17.05 (1.1-fold increase); and for sepsis, 6.31 versus 39.64 (6.3-fold increase). In 2011-2012, sepsis surpassed pneumonia as the most common hospitalized infection in patients with SLE. In multivariable-adjusted models, a diagnosis of sepsis, older age, a Deyo-Charlson common comorbidities score of ≥2, having Medicare or Medicaid insurance, and urban hospital location were significantly associated with increased odds of in-hospital mortality and with all health care utilization outcomes. African American race was significantly associated with increased odds of health care utilization. CONCLUSION The results of this study indicate that the rates of hospitalized infections increased over time in patients with SLE, and that pneumonia was surpassed by sepsis as the most common hospitalized infection. In addition, associations of risk factors with poorer outcomes were identified. These findings may help inform patients, providers, and policy makers with regard to the burden of infection in SLE, and could lead to interventions/pathways to improve outcomes.
Collapse
Affiliation(s)
- Jasvinder A Singh
- University of Alabama at Birmingham and Birmingham VA Medical Center
| | | |
Collapse
|
11
|
Rianthavorn P, Prurapark P. Infections in hospitalized children with newly diagnosed systemic lupus erythematosus in underresourced areas. Lupus 2020; 29:1475-1482. [DOI: 10.1177/0961203320939164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The administration of induction immunosuppressive therapy to children with newly diagnosed systemic lupus erythematosus (SLE) and concurrent infections can lead to unfavourable outcomes. This study was conducted to describe characteristics of infections occurring before the initiation of immunosuppressants in hospitalized children with newly diagnosed SLE in underresourced areas. Methods Medical records of paediatric patients with the diagnosis of SLE, who were admitted to a university-based hospital from 2002 to 2018, were reviewed. Only patients younger than 18 years of age with newly diagnosed SLE were included in the study. The primary outcome was infection before the administration of immunosuppressants. Logistic regression analysis was used to determine factors associated with infection and adjusted odds ratio (OR). The diagnostic accuracy of CRP was assessed. Results Infections were confirmed in 52/124 (41.9%) children. Pathogens were identified in 24 (46.2%) patients with bacterial predominance. The most common site was respiratory infections (36.5%). Fever and serosal involvement were more prevalent in patients with infection. Serum CRP levels were significantly higher in patients with infection than in those without infection (median 5.5 mg/L (interquartile range (IQR) 3.6–76.3 mg/L) vs. 3.5 mg/L (IQR 3.0–3.6 mg/L), p = 0.004). When a positive CRP level of >5 mg/L was used, positive CRP was found with a higher prevalence in patients with infection and was independently associated with infection (adjusted odds ratio (OR) = 28.6, 95% confidence interval (CI) 2.3–350.6; p = 0.009). Patients with infection had a longer hospital stay than patients without infection (median 20 days (IQR 13–25 days) vs. 15 days (IQR 9–24 days), p = 0.04). Sensitivity, specificity, positive predictive value and negative predictive value with 95% CI of CRP >5 mg/L were 62.5% (35.4–84.8%), 88.9% (65.3–98.6%), 80.3% (51.0–94.1%) and 76.6% (63.1–86.3%), respectively. Conclusions Infections were common among hospitalized children with newly diagnosed SLE. Children with infections had a prolonged course of hospitalization. Positive CRP was associated with a predisposition towards infection. However, the diagnostic accuracy of CRP requires further validation in a larger study.
Collapse
Affiliation(s)
- Pornpimol Rianthavorn
- Division of Nephrology, Department of Paediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pattareeya Prurapark
- Division of Nephrology, Department of Paediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| |
Collapse
|
12
|
Aydın F, Kurt T, Bedir T, Parlakay AÖ, Acar B. Hematological abnormalities resistant to therapy in a child with systemic lupus erythematosus: Answers. Pediatr Nephrol 2020; 35:1225-1226. [PMID: 31900632 DOI: 10.1007/s00467-019-04467-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 12/17/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Fatma Aydın
- Department of Pediatrics, Division of Pediatric Rheumatology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Tuba Kurt
- Department of Pediatrics, Division of Pediatric Rheumatology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Tuba Bedir
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Aslınur Özkaya Parlakay
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Banu Acar
- Department of Pediatrics, Division of Pediatric Rheumatology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey.
| |
Collapse
|
13
|
Abstract
INTRODUCTION Systemic lupus erythematosus (SLE) is an autoimmune disorder that affects almost every organ system and it is treated with immunomodulation and immunosuppression. SLE patients have an intrinsically dysfunctional immune system which is exacerbated by disease activity and leaves them vulnerable to infection. Treatment with immunosuppression increases susceptibility to infection, while hydroxychloroquine use decreases this risk. Infectious diseases are a leading cause of hospitalization and death. AREAS COVERED This narrative review provides an overview of recent epidemiology and predictors of infections in SLE, delineates the risk of infection by therapeutic agent, and provides suggestions for risk mitigation. Articles were selected from Pubmed searches conducted between September 2019 and January 2020. EXPERT OPINION Despite the large burden of infection, effective and safe preventative care such as universal hydroxychloroquine use and vaccination are underutilized. Future efforts should be directed to quality improvement, glucocorticoid reduction, and validation of risk indices that identify patients at the highest risk of infection.
Collapse
Affiliation(s)
- Megan R W Barber
- Division of Rheumatology, University of Calgary , Calgary, Alberta, Canada
| | - Ann E Clarke
- Division of Rheumatology, University of Calgary , Calgary, Alberta, Canada
| |
Collapse
|
14
|
Vela Casasempere P, Ruiz Torregrosa P, García Sevila R. Pneumocystis jirovecii in immunocompromised patients with rheumatic diseases. ACTA ACUST UNITED AC 2020; 17:290-296. [PMID: 32466869 DOI: 10.1016/j.reuma.2020.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 12/30/2019] [Accepted: 02/28/2020] [Indexed: 12/14/2022]
Abstract
Infections, including opportunistic infections, are a major and frequent cause of morbidity and mortality in patients with systemic autoimmune and rheumatic diseases. Pneumocystis jirovecii pneumonia, classically considered to be typical of HIV patients, transplanted patients or patients treated with oncological chemotherapy, is appearing increasingly frequently in these patients. Therefore, rheumatologists should know its mechanism of production, clinical manifestations, treatment and prophylaxis, all of which are addressed in this review.
Collapse
Affiliation(s)
- Paloma Vela Casasempere
- Sección de Reumatología. Hospital General Universitario de Alicante. ISABIAL, Alicante, España; Universidad Miguel Hernández, Alicante, España.
| | | | - Raquel García Sevila
- Servicio de Neumología. Hospital General Universitario de Alicante, Alicante, España
| |
Collapse
|
15
|
Fatal Disseminated Aspergillosis in a Patient with Systemic Lupus Erythematosus. Case Rep Infect Dis 2020; 2020:9623198. [PMID: 32181030 PMCID: PMC7066410 DOI: 10.1155/2020/9623198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 01/20/2020] [Accepted: 02/05/2020] [Indexed: 12/17/2022] Open
Abstract
Patients with systemic lupus erythematosus (SLE) are at increased risk for infection including opportunistic infections. Fungal infection in particular can be difficult to diagnose and treat and often can be life-threatening in the immunocompromised patient. We present a case in which a patient with SLE presented to the hospital with shortness of breath and cough. Throughout the hospital course, the patient's condition continued to decline leading to acute respiratory failure, and eventually, the patient expired. Postmortem autopsy revealed invasive fungal aspergillosis infection involving the heart, lungs, and brain. Earlier diagnosis and treatment with empiric antifungals may improve survival in these patients.
Collapse
|
16
|
Cervera R, Mosca M, Ríos-Garcés R, Espinosa G, Trujillo H, Bada T, Praga M. Treatment for refractory lupus nephritis: Rituximab vs triple target therapy. Autoimmun Rev 2019; 18:102406. [DOI: 10.1016/j.autrev.2019.102406] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 07/07/2019] [Indexed: 12/12/2022]
|
17
|
Aragón CC, Nieto-Aristizábal I, Ríos-Serna LJ, Barrera MC, Naranjo-Escobar J, Posso-Osorio I, Lara-Erazo V, Leib P, Moreno-Angarita A, Aguirre-Valencia D, Echeverri A, Cañas CA, Tobón GJ. Pentraxin 3 is useful to differentiate infections from flares in patients with systemic lupus erythematosus who present systemic inflammatory response. Lupus 2019; 28:1279-1280. [DOI: 10.1177/0961203319870240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- C C Aragón
- Grupo de Investigación en Reumatología, Universidad Icesi and Fundación Valle del Lili, Cali, Colombia
| | - I Nieto-Aristizábal
- Grupo de Investigación en Reumatología, Universidad Icesi and Fundación Valle del Lili, Cali, Colombia
| | - L J Ríos-Serna
- Grupo de Investigación en Reumatología, Universidad Icesi and Fundación Valle del Lili, Cali, Colombia
| | - M C Barrera
- Grupo de Investigación en Reumatología, Universidad Icesi and Fundación Valle del Lili, Cali, Colombia
| | - J Naranjo-Escobar
- Grupo de Investigación en Reumatología, Universidad Icesi and Fundación Valle del Lili, Cali, Colombia
| | - I Posso-Osorio
- Grupo de Investigación en Reumatología, Universidad Icesi and Fundación Valle del Lili, Cali, Colombia
| | - V Lara-Erazo
- Grupo de Investigación en Reumatología, Universidad Icesi and Fundación Valle del Lili, Cali, Colombia
- Medical School, Universidad Icesi, Cali, Colombia
| | - P Leib
- Grupo de Investigación en Reumatología, Universidad Icesi and Fundación Valle del Lili, Cali, Colombia
- Medical School, Universidad Icesi, Cali, Colombia
| | - A Moreno-Angarita
- Grupo de Investigación en Reumatología, Universidad Icesi and Fundación Valle del Lili, Cali, Colombia
- Medical School, Universidad Icesi, Cali, Colombia
| | - D Aguirre-Valencia
- Grupo de Investigación en Reumatología, Universidad Icesi and Fundación Valle del Lili, Cali, Colombia
| | - A Echeverri
- Grupo de Investigación en Reumatología, Universidad Icesi and Fundación Valle del Lili, Cali, Colombia
| | - C A Cañas
- Grupo de Investigación en Reumatología, Universidad Icesi and Fundación Valle del Lili, Cali, Colombia
| | - G J Tobón
- Grupo de Investigación en Reumatología, Universidad Icesi and Fundación Valle del Lili, Cali, Colombia
| |
Collapse
|
18
|
Wang J, Niu R, Jiang L, Wang Y, Shao X, Wu M, Ma Y. The diagnostic values of C-reactive protein and procalcitonin in identifying systemic lupus erythematosus infection and disease activity. Medicine (Baltimore) 2019; 98:e16798. [PMID: 31415387 PMCID: PMC6831178 DOI: 10.1097/md.0000000000016798] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
To explore the values of C-reactive protein (CRP) and procalcitonin (PCT) in identifying infection and disease activity in systemic lupus erythematosus (SLE) patients.Patients with SLE and infection from April 2015 to January 2018 were included in this study. We compared the clinical characteristics and biomarkers between different groups and calculated the receiver operating characteristic curve, sensitivity, and specificity of the corresponding biomarkers. Logistic regression analysis was performed on the variables exhibiting significant differences in univariate analysis.A total of 177 SLE patients were retrospectively analyzed. The patients were divided into noninfected-inactive group, noninfected-active group, infected-inactive group, and infected-active group. CRP level of infected-inactive group was significantly higher than noninfected-inactive group (P < .05), but not significantly in infected-active group than noninfected-active group (P > .05). Multivariate analysis showed that CRP (>24.0 mg/L) was the only independent risk factor for SLE infection (odds ratio, OR = 2.896, P = .032). PCT level of infected-active group was significantly higher than infected-inactive group (P < .05), but not significantly in noninfected-active group than noninfected-inactive group (P > .05). SLE active group had shorter disease course, lower infection rate, higher PCT level, and lower platelet count (PLT). Multivariate logistic analysis showed that PCT (>0.048 ng/mL) and PLT (<150 × 10/L) were independent risk factors for SLE activity (OR = 3.498 and 4.391, P = .011 and 0.009), and disease course (>96 months) was independent protective factor (OR = 0.169, P < .001). The area under the curve of the logistic model was significantly larger than any single variable (all P < .05).CRP is the only effective marker for diagnosing infection in SLE patients. Moreover, PCT helps predict SLE activity.
Collapse
Affiliation(s)
| | | | | | | | | | - Min Wu
- Department of Rheumatology and Immunology, the Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Yingchun Ma
- Department of Rheumatology and Immunology, the Third Affiliated Hospital of Soochow University, Changzhou, China
| |
Collapse
|
19
|
Choo HMC, Cher WQ, Kwan YH, Fong WWS. Risk factors for cytomegalovirus disease in systemic lupus erythematosus (SLE): a systematic review. Adv Rheumatol 2019; 59:12. [PMID: 30885265 DOI: 10.1186/s42358-019-0055-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 03/06/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) is an opportunistic pathogen causing reactivation and disease in Systemic Lupus Erythematosus (SLE) patients. This study aims to systematically review the literature for risk factors associated with CMV disease in SLE patients, in order to identify those more susceptible to CMV infection during their treatment. METHODS A systematic review was conducted on 4 different search engines and via hand search until May 2017. Studies were included after quality assessment via the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields (HTA KMET). RESULTS Two studies on CMV disease were included. Elevated CMV viral load, higher steroid doses, use of immunosuppressants and disease duration were the most commonly associated risk factors for CMV disease. CONCLUSION High CMV viral loads, longer SLE disease duration and higher steroid doses were associated with CMV disease. Further studies studying the risk of treatment drugs and role of interventions in the development of CMV infection are needed.
Collapse
Affiliation(s)
- Hui Min Charlotte Choo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore. .,Department of Internal Medicine, Singapore General Hospital, Academia Building, Level 4, 20 College Road, Singapore, 169856, Singapore.
| | - Wen Qi Cher
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yu Heng Kwan
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Warren Weng Seng Fong
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, Singapore
| |
Collapse
|
20
|
Torres-Ruiz J, Mejía-Domínguez NR, Zentella-Dehesa A, Ponce-de-León A, Morales-Padilla SR, Vázquez-Rodríguez R, Alvarado-Lara MR, Reyna-de-la-Garza RA, Tapia-Rodríguez M, Juárez-Vega G, Merayo-Chalico J, Barrera-Vargas A, Alcocer-Varela JC, Gómez-Martín D. The Systemic Lupus Erythematosus Infection Predictive Index (LIPI): A Clinical-Immunological Tool to Predict Infections in Lupus Patients. Front Immunol 2019; 9:3144. [PMID: 30692998 PMCID: PMC6340073 DOI: 10.3389/fimmu.2018.03144] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 12/19/2018] [Indexed: 12/16/2022] Open
Abstract
Among autoimmune diseases, systemic lupus erythematosus (SLE) patients have a unique predisposition to develop infections, which represents one of their main causes of morbidity and mortality. Many infections occur at disease diagnosis in the absence of immunosuppressive therapy, suggesting that the immunological abnormalities in SLE patients might be fundamental for the development of this complication. The aim of this study was to address the main clinical and immunological features associated with the development of infection and to create and validate a compound clinical-immunological infection predictive index in a cohort of SLE patients. We included 55 SLE patients with < 5 years since diagnosis. The clinical and immunological features were evaluated periodically and patients were followed-up during 1 year, searching for the development of infection. Immunophenotyping was performed by multiparametric flow cytometry and neutrophil extracellular traps (NETs) were assessed by confocal microscopy. Eighteen patients (32.7%) presented 19 infectious events, 5 (26.3%) were severe. For the construction of the index, we performed a logistic regression analysis and the cutoff points were determined with ROC curves. Increased numbers of peripheral Th17 cells, B cell lymphopenia, and lower TLR2 expression in monocytes, as well as the use of cyclophosphamide were the major risk factors for the development of infection and thus were included in the index. Besides, patients that developed infection were characterized by increased numbers of low-density granulocytes (LDGs) and higher expression of LL-37 in NETs upon infection. Finally, we validated the index retrospectively in a nested case-control study. A score >1.5 points was able to predict infection in the following year (AUC = 0.97; LR- = 0.001, specificity 100%, P = 0.0003). Our index encompasses novel immunological features able to prospectively predict the risk of infection in SLE patients.
Collapse
Affiliation(s)
- Jiram Torres-Ruiz
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.,Emergency Medicine Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Nancy R Mejía-Domínguez
- Bioinformatics, Biostatistics and Computational Biology Unit, Red de Apoyo a la Investigación, Coordinación de la Investigación Científica, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Alejandro Zentella-Dehesa
- Department of Genomic Medicine and Environmental Toxicology, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Alfredo Ponce-de-León
- Department of Infectology and Microbiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Sandra Rubí Morales-Padilla
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ricardo Vázquez-Rodríguez
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Mario René Alvarado-Lara
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Roberto Adrián Reyna-de-la-Garza
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Miguel Tapia-Rodríguez
- Microscopy Unit, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Guillermo Juárez-Vega
- Flow Cytometry Unit, Red de Apoyo a la Investigación, Coordinación de Investigación Científica, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Javier Merayo-Chalico
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ana Barrera-Vargas
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Jorge C Alcocer-Varela
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Diana Gómez-Martín
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.,Flow Cytometry Unit, Red de Apoyo a la Investigación, Coordinación de Investigación Científica, Universidad Nacional Autónoma de México, Mexico City, Mexico
| |
Collapse
|
21
|
Echeverri A, Naranjo-Escobar J, Posso-Osorio I, Aguirre-Valencia D, Zambrano D, Castaño GL, Martínez JD, Cañas CA, Tobón GJ. Neutrophil CD64 expression, procalcitonin and presepsin are useful to differentiate infections from flares in SLE patients with SIRS. Lupus 2018. [PMID: 29540108 DOI: 10.1177/0961203318763740] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background/Objective Differentiating systemic lupus erythematosus (SLE) activity from infections in febrile patients is difficult because of similar initial clinical presentation. The aim of this study is to evaluate the usefulness of a number of biomarkers for differentiating infections from activity in SLE patients admitted with systemic inflammatory response (SIRS). Methods Patients with SLE and SIRS admitted to the emergency room were included in this study. Measurements of different markers including procalcitonin, neutrophil CD64 expression and presepsin, were performed. Infection was considered present when positive cultures and/or polymerase chain reaction were obtained. Sensitivity and specificity were calculated for all biomarkers. Results Twenty-seven patients were admitted, 23 women (82.5%), mean age 33.2 years. An infectious disease was confirmed in 12 cases. Markers for SLE activity including anti-DNA titers by IIF ( p = 0.041) and enzyme-linked immunosorbent assay ( p = 0.009) were used for differentiating SLE flares from infection. On the contrary, increased procalcitonin ( p = 0.047), neutrophil CD64 expression by flow cytometry ( p = 0.037) and presepsin ( p = 0.037) levels were observed in infected SLE patients. Conclusions High neutrophil CD64 expression, presepsin and procalcitonin levels are useful to differentiate infections from activity in SLE patients. In most cases, a positive bioscore that includes these three markers demonstrate the presence of an infectious disease.
Collapse
Affiliation(s)
- A Echeverri
- 1 Grupo de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional (GIRAT), School of Medicine, Universidad Icesi, and Fundación Valle del Lili, Cali, Colombia
| | - J Naranjo-Escobar
- 1 Grupo de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional (GIRAT), School of Medicine, Universidad Icesi, and Fundación Valle del Lili, Cali, Colombia
| | - I Posso-Osorio
- 1 Grupo de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional (GIRAT), School of Medicine, Universidad Icesi, and Fundación Valle del Lili, Cali, Colombia
| | - D Aguirre-Valencia
- 1 Grupo de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional (GIRAT), School of Medicine, Universidad Icesi, and Fundación Valle del Lili, Cali, Colombia.,2 Universidad Icesi, Medical School, Cali, Colombia
| | - D Zambrano
- 3 Universidad CES, Medical School, Medellin, Colombia
| | - G L Castaño
- 4 Immunology Laboratory, Fundación Valle del Lili, Cali, Colombia
| | - J D Martínez
- 4 Immunology Laboratory, Fundación Valle del Lili, Cali, Colombia
| | - C A Cañas
- 1 Grupo de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional (GIRAT), School of Medicine, Universidad Icesi, and Fundación Valle del Lili, Cali, Colombia
| | - G J Tobón
- 1 Grupo de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional (GIRAT), School of Medicine, Universidad Icesi, and Fundación Valle del Lili, Cali, Colombia.,4 Immunology Laboratory, Fundación Valle del Lili, Cali, Colombia
| |
Collapse
|
22
|
Krasselt M, Baerwald C, Seifert O. Insufficient vaccination rates in patients with systemic lupus erythematosus in a German outpatient clinic. Z Rheumatol 2017; 77:727-734. [DOI: 10.1007/s00393-017-0410-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
23
|
Bragazzi NL, Watad A, Sharif K, Adawi M, Aljadeff G, Amital H, Shoenfeld Y. Advances in our understanding of immunization and vaccines for patients with systemic lupus erythematosus. Expert Rev Clin Immunol 2017; 13:939-949. [DOI: 10.1080/1744666x.2017.1361321] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Nicola Luigi Bragazzi
- School of Public Health, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Abdulla Watad
- Departement of Medicine ‘B’, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Kassem Sharif
- Departement of Medicine ‘B’, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Mohammad Adawi
- Faculty of Medicine, Baruch Padeh Medical Center, Bar-Ilan University, Israel
| | - Gali Aljadeff
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Howard Amital
- Departement of Medicine ‘B’, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yehuda Shoenfeld
- Departement of Medicine ‘B’, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| |
Collapse
|
24
|
Ospina FE, Echeverri A, Zambrano D, Suso JP, Martínez-Blanco J, Cañas CA, Tobón GJ. Distinguishing infections vs flares in patients with systemic lupus erythematosus. Rheumatology (Oxford) 2017; 56:i46-i54. [PMID: 27744359 DOI: 10.1093/rheumatology/kew340] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Indexed: 12/20/2022] Open
Abstract
SLE is a chronic autoimmune disease involving multiple systems. Patients with SLE are highly susceptible to infections due to the combined effects of their immunosuppressive therapy and the abnormalities of the immune system that the disease itself causes, which can increase mortality in these patients. The differentiation of SLE activity and infection in a febrile patient with SLE is extremely difficult. Activity indexes are useful to identify patients with lupus flares but some clinical and biological abnormalities may, however, make it difficult to differentiate flares from infection. Several biological markers are now recognized as potential tools to establish the difference between SLE activity and infection, including CRP and procalcitonin. It is possible, however, that the use of only one biomarker is not sufficient to confirm or discard infection. This means that new scores, which include different biomarkers, might represent a better solution for differentiating these two clinical pictures. This review article describes several markers that are currently used, or have the potential, to differentiate infection from SLE flares.
Collapse
Affiliation(s)
- Fabio E Ospina
- Rheumatology Unit, Fundación Valle del Lili, ICESI University.,Clinical Investigation InstituteFundación Valle del Lili
| | - Alex Echeverri
- Rheumatology Unit, Fundación Valle del Lili, ICESI University
| | - Diana Zambrano
- Internal Medicine, Fundación Valle del Lili, ICESI University
| | - Juan-Pablo Suso
- Rheumatology Unit, Fundación Valle del Lili, ICESI University.,Clinical Investigation InstituteFundación Valle del Lili
| | | | - Carlos A Cañas
- Rheumatology Unit, Fundación Valle del Lili, ICESI University
| | - Gabriel J Tobón
- Rheumatology Unit, Fundación Valle del Lili, ICESI University.,Internal Medicine, Fundación Valle del Lili, ICESI University
| |
Collapse
|
25
|
Watad A, Azrielant S, Bragazzi NL, Sharif K, David P, Katz I, Aljadeff G, Quaresma M, Tanay G, Adawi M, Amital H, Shoenfeld Y. Seasonality and autoimmune diseases: The contribution of the four seasons to the mosaic of autoimmunity. J Autoimmun 2017. [PMID: 28624334 DOI: 10.1016/j.jaut.2017.06.001] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Autoimmune diseases (ADs) are a heterogeneous groups of diseases that occur as a results of loss of tolerance to self antigens. While the etiopathogeneis remain obscure, different environmental factors were suggested to have a role in the development of autoimmunity, including infections, low vitamin D levels, UV radiation, and melatonin. Interestingly, such factors possess seasonal variation patterns that could influence disease development, severity and progression. Vitamin D levels which reach a nadir during late winter and early spring is correlated with increased disease activity, clinical severity as well as relapse rates in several disease entities including multiple sclerosis (MS), non-cutaneous flares of systemic lupus erythematosus (SLE), psoriasis, and rheumatoid arthritis (RA). Additionally, immunomodulatory actions of melatonin secretion ameliorate the severity of several ADs including MS and SLE. Melatonin levels are lowest during spring, a finding that correlates with the highest exacerbation rates of MS. Further, melatonin is postulated to be involved in the etiopathogenesis of inflammatory bowel diseases (IBD) through it influence on adhesion molecule and therefore transcription factor expression. Moreover, infections can mount to ADs through pro-inflammatory cytokine release and human antigen mimicry. Seasonal patterns of infectious diseases are correlated with the onset and exacerbation of ADs. During the winter, increased incidence of Epstein-Barr virus (EBV) infectious are associated with MS and SLE flares/onset respectively. In addition, higher Rotavirus infections during the winter precedes type 1 diabetes mellitus onset (T1DM). Moreover, Escherichia coli (E. coli) infection prior to primary biliary cirrhosis (PBC) and T1DM disease onset subsequent to Coxachievirus infections are seen to occur during late summer, a finding that correlate with infectious agents' pattern of seasonality. In this review, the effects of seasonality on the onset, relapses and activity of various ADs were discussed. Consideration of seasonal variation patterns of ADs can possibly provide clues to diseases pathogenesis and lead to development of new approaches in treatment and preventative care.
Collapse
Affiliation(s)
- Abdulla Watad
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer, Israel; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Shir Azrielant
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nicola Luigi Bragazzi
- Postgraduate School of Public Health, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Kassem Sharif
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Paula David
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - Itay Katz
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - Gali Aljadeff
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - Mariana Quaresma
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - Galya Tanay
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - Mohammad Adawi
- Baruch Padeh and Ziv hospitals, Bar-Ilan, Faculty of Medicine, Zefat, Israel
| | - Howard Amital
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer, Israel; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Incumbent of the Laura Schwarz-Kipp Chair for Research of Autoimmune Diseases, Tel-Aviv University, Israel.
| |
Collapse
|
26
|
Rúa-Figueroa Í, López-Longo J, Galindo-Izquierdo M, Calvo-Alén J, Del Campo V, Olivé-Marqués A, Pérez-Vicente S, Fernández-Nebro A, Andrés M, Erausquin C, Tomero E, Horcada L, Uriarte E, Freire M, Montilla C, Sánchez-Atrio A, Santos G, Boteanu A, Díez-Álvarez E, Narváez J, Martínez-Taboada V, Silva-Fernández L, Ruiz-Lucea E, Andreu JL, Hernández-Beriain JÁ, Gantes M, Hernández-Cruz B, Pérez-Venegas J, Pecondón-Español Á, Marras C, Ibáñez-Barceló M, Bonilla G, Torrente V, Castellví I, Alegre JJ, Calvet J, Marenco JL, Raya E, Vázquez T, Quevedo V, Muñoz-Fernández S, Rodríguez-Gómez M, Ibáñez J, Pego-Reigosa JM. Incidence, associated factors and clinical impact of severe infections in a large, multicentric cohort of patients with systemic lupus erythematosus. Semin Arthritis Rheum 2017; 47:38-45. [PMID: 28259425 DOI: 10.1016/j.semarthrit.2017.01.010] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Revised: 01/16/2017] [Accepted: 01/23/2017] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To estimate the incidence of severe infection and investigate the associated factors and clinical impact in a large systemic lupus erythematosus (SLE) retrospective cohort. METHODS All patients in the Spanish Rheumatology Society Lupus Registry (RELESSER) who meet ≥4 ACR-97 SLE criteria were retrospectively investigated for severe infections. Patients with and without infections were compared in terms of SLE severity, damage, comorbidities, and demographic characteristics. A multivariable Cox regression model was built to calculate hazard ratios (HRs) for the first infection. RESULTS A total of 3658 SLE patients were included: 90% female, median age 32.9 years (DQ 9.7), and mean follow-up (months) 120.2 (±87.6). A total of 705 (19.3%) patients suffered ≥1 severe infection. Total severe infections recorded in these patients numbered 1227. The incidence rate was 29.2 (95% CI: 27.6-30.9) infections per 1000 patient years. Time from first infection to second infection was significantly shorter than time from diagnosis to first infection (p < 0.000). Although respiratory infections were the most common (35.5%), bloodstream infections were the most frequent cause of mortality by infection (42.0%). In the Cox regression analysis, the following were all associated with infection: age at diagnosis (HR = 1.016, 95% CI: 1.009-1.023), Latin-American (Amerindian-Mestizo) ethnicity (HR = 2.151, 95% CI: 1.539-3.005), corticosteroids (≥10mg/day) (HR = 1.271, 95% CI: 1.034-1.561), immunosuppressors (HR = 1.348, 95% CI: 1.079-1.684), hospitalization by SLE (HR = 2.567, 95% CI: 1.905-3.459), Katz severity index (HR = 1.160, 95% CI: 1.105-1.217), SLICC/ACR damage index (HR = 1.069, 95% CI: 1.031-1.108), and smoking (HR = 1.332, 95% CI: 1.121-1.583). Duration of antimalarial use (months) proved protective (HR = 0.998, 95% CI: 0.997-0.999). CONCLUSIONS Severe infection constitutes a predictor of poor prognosis in SLE patients, is more common in Latin-Americans and is associated with age, previous infection, and smoking. Antimalarials exerted a protective effect.
Collapse
Affiliation(s)
- Íñigo Rúa-Figueroa
- Rheumatology Department, Doctor Negrín University Hospital Las Palmas de Gran Canaria, Bco. de la Ballena s/n, 35020 Las Palmas, Spain.
| | - Javier López-Longo
- Rheumatology Department, Gregorio Marañón University Hospital, Madrid, Spain
| | | | - Jaime Calvo-Alén
- Rheumatology Department, Sierrallana Hospital, Torrelavega, Spain
| | - Víctor Del Campo
- Preventive Medicine Service, Biomedical Research Institute of Vigo (IBIV), University Hospital Complex of Vigo, Vigo, Spain
| | | | - Sabina Pérez-Vicente
- Statistical Department, Research Unit, Spanish Society of Rheumatology (SER), Madrid, Spain
| | | | - Mariano Andrés
- Rheumatology Department, Hospital of Alicante, Alicante, Spain
| | - Celia Erausquin
- Rheumatology Department, Doctor Negrín University Hospital Las Palmas de Gran Canaria, Bco. de la Ballena s/n, 35020 Las Palmas, Spain
| | - Eva Tomero
- Rheumatology Department, La Princesa University Hospital, Madrid, Spain
| | - Loreto Horcada
- Rheumatology Department, Hospital of Navarra, Pamplona, Spain
| | - Esther Uriarte
- Rheumatology Department, Donostia Hospital, Donostia, Guipuzcoa, Spain
| | - Mercedes Freire
- Rheumatology Department, University Hospital Complex of A Coruña, A Coruña, Spain
| | - Carlos Montilla
- Rheumatology Department, Salamanca University Hospital, Salamanca, Spain
| | - Ana Sánchez-Atrio
- System Diseases and Oncology Service, Príncipe de Asturias University Hospital Alcalá de Henares, Madrid, Spain
| | - Gregorio Santos
- Rheumatology Department, Marina Baixa Hospital, Alicante, Spain
| | - Alina Boteanu
- Rheumatology Department, Ramon y Cajal University Hospital, Madrid, Spain
| | | | - Javier Narváez
- Rheumatology Department, Bellvitge Hospital, Barcelona, Spain
| | | | | | | | - José Luis Andreu
- Rheumatology Department, Puerta de Hierro-Majadahonda Hospital, Madrid, Spain
| | | | - Marian Gantes
- Rheumatology Department, University Hospital of Canarias, Tenerife, Spain
| | | | - José Pérez-Venegas
- Rheumatology Department, Jerez de la Frontera University Hospital, Cádiz, Spain
| | | | - Carlos Marras
- Rheumatology Department, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | | | - Gema Bonilla
- Rheumatology Department, La Paz University Hospital, Madrid, Spain
| | - Vicente Torrente
- Rheumatology Department, Hospital of Hospitalet-Moisés Broggi CSI, Barcelona, Spain
| | - Iván Castellví
- Rheumatology Unit, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | | | - Joan Calvet
- Rheumatology Department, Parc Taulí Hospital, Barcelona, Spain
| | - Jose Luis Marenco
- Rheumatology Department, Virgen de Valme University Hospital, Sevilla, Spain
| | - Enrique Raya
- Rheumatology Department, San Cecilio Hospital, Granada, Spain
| | - Tomás Vázquez
- Rheumatology Department, Lucus Augusti Hospital, Lugo, Spain
| | | | | | | | - Jesús Ibáñez
- Rheumatology Unit, POVISA Medical Center, Vigo, Spain
| | - José M Pego-Reigosa
- Rheumatology Department, Biomedical Research Institute of Vigo (IBIV), University Hospital Complex of Vigo, Vigo, Spain
| |
Collapse
|
27
|
Murdaca G, Orsi A, Spanò F, Faccio V, Puppo F, Durando P, Icardi G, Ansaldi F. Vaccine-preventable infections in Systemic Lupus Erythematosus. Hum Vaccin Immunother 2016; 12:632-43. [PMID: 26750996 PMCID: PMC4964666 DOI: 10.1080/21645515.2015.1107685] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 09/29/2015] [Accepted: 10/09/2015] [Indexed: 12/26/2022] Open
Abstract
Systemic Lupus Erythematosus (SLE) is characterized by abnormal autoantibody production and clearance. Infections are among the most important causes of morbidity and mortality in SLE patients; they have an increased frequency of severe bacterial and viral infections possibly due to inherited genetic and immunologic defects and to immunosuppressive therapies. In addition, infectious agents can switch on lupus disease expression and activity. Among the strategies to reduce the risk of infection, vaccination can be considered the most reliable option. Most vaccines are effective and safe in SLE patients, although in certain cases immunogenicity may be sub-optimal and vaccination can trigger a flare. Although these issues are currently unresolved, the risk benefit balance is in favor for vaccination to reduce the risk of infection in SLE patients. In the present review we discuss the preventive strategies currently recommended to reduce bacterial and viral infections in SLE.
Collapse
Affiliation(s)
- Giuseppe Murdaca
- Department of Internal Medicine, University of Genoa, Genoa, Italy and Clinical Immunology Unit, I.R.C.C.S. University Hospital San Martino - IST National Institute for Cancer Research, Genoa, Italy
| | - Andrea Orsi
- Department of Health Sciences, University of Genoa, Genoa, Italy and Hygiene Unit, I.R.C.C.S. University Hospital San Martino - IST National Institute for Cancer Research, Genoa, Italy
| | - Francesca Spanò
- Department of Internal Medicine, University of Genoa, Genoa, Italy and Clinical Immunology Unit, I.R.C.C.S. University Hospital San Martino - IST National Institute for Cancer Research, Genoa, Italy
| | - Valeria Faccio
- Department of Health Sciences, University of Genoa, Genoa, Italy and Hygiene Unit, I.R.C.C.S. University Hospital San Martino - IST National Institute for Cancer Research, Genoa, Italy
| | - Francesco Puppo
- Department of Internal Medicine, University of Genoa, Genoa, Italy and Clinical Immunology Unit, I.R.C.C.S. University Hospital San Martino - IST National Institute for Cancer Research, Genoa, Italy
| | - Paolo Durando
- Department of Health Sciences, University of Genoa, Genoa, Italy and Occupational Medicine Unit, I.R.C.C.S. University Hospital San Martino - IST National Institute for Cancer Research, Genoa, Italy
| | - Giancarlo Icardi
- Department of Health Sciences, University of Genoa, Genoa, Italy and Hygiene Unit, I.R.C.C.S. University Hospital San Martino - IST National Institute for Cancer Research, Genoa, Italy
| | - Filippo Ansaldi
- Department of Health Sciences, University of Genoa, Genoa, Italy and Hygiene Unit, I.R.C.C.S. University Hospital San Martino - IST National Institute for Cancer Research, Genoa, Italy
| |
Collapse
|
28
|
Abstract
Though rare, childhood lupus is a disease with the potential to have serious short and long term effects in children. These effects are to do with the disease itself, organ damage consequent to ongoing inflammation and/or because of side effects of medications. As children have an early disease onset, accrual organ damage over the years and growth and puberty issues are important aspects of care. Thus it is essential to recognize the disease early, objectively assess the patient at regular intervals, treat to a target of remission and limit the use of steroids as far as possible. This review focuses on the elements that help identify these patients in the clinic, discusses the role of objective disease assessment and outlines management and co-morbidities in these patients.
Collapse
|
29
|
Murray SG, Schmajuk G, Trupin L, Gensler L, Katz PP, Yelin EH, Gansky SA, Yazdany J. National Lupus Hospitalization Trends Reveal Rising Rates of Herpes Zoster and Declines in Pneumocystis Pneumonia. PLoS One 2016; 11:e0144918. [PMID: 26731012 PMCID: PMC4701172 DOI: 10.1371/journal.pone.0144918] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 11/26/2015] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE Infection is a leading cause of morbidity and mortality in systemic lupus erythematosus (SLE). Therapeutic practices have evolved over the past 15 years, but effects on infectious complications of SLE are unknown. We evaluated trends in hospitalizations for severe and opportunistic infections in a population-based SLE study. METHODS Data derive from the 2000 to 2011 United States National Inpatient Sample, including individuals who met a validated administrative definition of SLE. Primary outcomes were diagnoses of bacteremia, pneumonia, opportunistic fungal infection, herpes zoster, cytomegalovirus, or pneumocystis pneumonia (PCP). We used Poisson regression to determine whether infection rates were changing in SLE hospitalizations and used predictive marginals to generate annual adjusted rates of specific infections. RESULTS We identified 361,337 SLE hospitalizations from 2000 to 2011 meeting study inclusion criteria. Compared to non-SLE hospitalizations, SLE patients were younger (51 vs. 62 years), predominantly female (89% vs. 54%), and more likely to be racial/ethnic minorities. SLE diagnosis was significantly associated with all measured severe and opportunistic infections. From 2000 to 2011, adjusted SLE hospitalization rates for herpes zoster increased more than non-SLE rates: 54 to 79 per 10,000 SLE hospitalizations compared with 24 to 29 per 10,000 non-SLE hospitalizations. Conversely, SLE hospitalizations for PCP disproportionately decreased: 5.1 to 2.5 per 10,000 SLE hospitalizations compared with 0.9 to 1.3 per 10,000 non-SLE hospitalizations. CONCLUSIONS Among patients with SLE, herpes zoster hospitalizations are rising while PCP hospitalizations are declining. These trends likely reflect evolving SLE treatment strategies. Further research is needed to identify patients at greatest risk for infectious complications.
Collapse
Affiliation(s)
- Sara G. Murray
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Gabriela Schmajuk
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
- Department of Medicine, Veterans Administration, San Francisco, California, United States of America
| | - Laura Trupin
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Lianne Gensler
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Patricia P. Katz
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
- Phillip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, United States of America
| | - Edward H. Yelin
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
- Phillip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, United States of America
| | - Stuart A. Gansky
- Division of Oral Epidemiology and Dental Public Health, Department of Preventive and Restorative Dental Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Jinoos Yazdany
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
- Phillip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, United States of America
| |
Collapse
|
30
|
Fakhreldin S, Gamal SM, Saad AS. Predictive potential of the disease activity index and C-reactive protein for infection in systemic lupus erythematosus patients. EGYPTIAN RHEUMATOLOGIST 2015. [DOI: 10.1016/j.ejr.2014.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
|
31
|
Gupta N, Lawrence RM, Nguyen C, Modica RF. Review article: BK virus in systemic lupus erythematosus. Pediatr Rheumatol Online J 2015; 13:34. [PMID: 26293687 PMCID: PMC4545992 DOI: 10.1186/s12969-015-0033-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 08/16/2015] [Indexed: 02/08/2023] Open
Abstract
BK virus (BKV) is a human polyomavirus with a seroprevalence of 60-80 % in the general population. In renal transplant patients, it is known to cause renal failure, ureteric stenosis and hemorrhagic cystitis. In bone marrow transplant patients, it is evident that BKV can also cause hemorrhagic cystitis along with BK virus nephropathy (BKVN) in the native kidneys, with subsequent renal failure. However, little is known about BVKN in non-transplanted immune-compromised patients, such as systemic lupus erythematosus (SLE) who may have underlying nephritis and have a compromised immune system due to therapy and/or systemic illness. Thus, this article will focus on the clinical aspects of BKV and its association in patients with SLE.
Collapse
Affiliation(s)
- Nirupama Gupta
- Division of Nephrology, Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL, 32610, USA.
| | - Robert M. Lawrence
- Division of Immunology, Rheumatology and Infectious Diseases, Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL 32610 USA
| | - Cuong Nguyen
- Department of Infectious Diseases and Pathology, College of Veterinary Medicine, University of Florida, Gainesville, FL, 32610, USA.
| | - Renee F. Modica
- Division of Immunology, Rheumatology and Infectious Diseases, Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL 32610 USA
| |
Collapse
|
32
|
Tektonidou MG, Wang Z, Dasgupta A, Ward MM. Burden of Serious Infections in Adults With Systemic Lupus Erythematosus: A National Population-Based Study, 1996-2011. Arthritis Care Res (Hoboken) 2015; 67:1078-85. [PMID: 25732901 PMCID: PMC4516647 DOI: 10.1002/acr.22575] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Revised: 02/09/2015] [Accepted: 02/24/2015] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To compare rates of hospitalization for serious infections, trends in rates from 1996 to 2011, and in-hospital mortality between patients with systemic lupus erythematosus (SLE) and those without SLE in a national sample. METHODS We analyzed hospitalizations for pneumonia, bacteremia/sepsis, urinary tract infections, skin infections, and opportunistic infections among adults in the Nationwide Inpatient Sample. We compared rates of hospitalization yearly among patients with SLE and the general population. We also computed odds ratios (ORs) for in-hospital mortality. RESULTS In 1996, the estimated number of hospitalizations for pneumonia in patients with SLE was 4,382, followed by sepsis (2,305), skin infections (1,422), urinary tract infections (643), and opportunistic infections (370). Rates were much higher in patients with SLE than in those without SLE, with age-adjusted relative risks ranging from 5.7 (95% confidence interval [95% CI] 5.5-6.0) for pneumonia to 9.8 (95% CI 9.1-10.7) for urinary tract infection in 1996. Risks increased over time, so that by 2011, all relative risks exceeded 12.0. Overall risk of in-hospital mortality was higher in SLE only for opportunistic infections (adjusted OR 1.52 [95% CI 1.12-2.07]). However, in pneumonia and sepsis, mortality risks were higher in SLE among those who required mechanical ventilation. CONCLUSION Hospitalization rates for serious infections in SLE increased substantially between 1996 and 2011, reaching over 12 times higher than in patients without SLE in 2011. Reasons for this acceleration are unclear. In-hospital mortality was higher among patients with SLE and opportunistic infections and those with pneumonia or sepsis who required mechanical ventilation.
Collapse
Affiliation(s)
| | - Zhong Wang
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | - Abhijit Dasgupta
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | - Michael M Ward
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| |
Collapse
|
33
|
Update on infections and vaccinations in systemic lupus erythematosus and Sjögren's syndrome. Curr Opin Rheumatol 2015; 26:528-37. [PMID: 25022358 DOI: 10.1097/bor.0000000000000084] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To provide an update on infections in systemic lupus erythematosus (SLE) and Sjögren's syndrome, particularly addressing their role as triggers of autoimmunity, their impact on mortality, the main microorganisms, the approaches to differential diagnosis with disease flares and recommendations for vaccination. RECENT FINDINGS New mechanisms for autoimmunity triggered by Epstein-Barr virus and human commensal microbiota have been described. The increased risk for tuberculosis was recently demonstrated for the first time in Sjögren's syndrome. C-reactive protein was reported to be a more sensitive and specific marker for bacterial infections in SLE than procalcitonin and phagocyte-specific S100A8/A9 protein. Inactivated vaccines are well tolerated and efficacy was demonstrated for influenza vaccine. Immunogenicity is generally reduced but adequate in SLE. Prednisone or immunosuppressants are associated with decreased vaccine serological response, whereas hydroxicloroquine seems to improve vaccine immunogenicity. Other infection-preventive measures for these diseases include antimalarials and prophylaxis for tuberculosis or Pneumocystis jirovecii. SUMMARY Advances in the role of infectious agents as triggers for SLE and Sjögren's syndrome have provided new insights into disease development. Knowledge on vaccine immunogenicity, safety and efficacy has improved with evidence of a generally reduced but adequate response for inactivated vaccines in SLE. Other preventive measures comprise infection prophylaxis and antimalarials.
Collapse
|
34
|
Dubula T, Mody GM. Spectrum of infections and outcome among hospitalized South Africans with systemic lupus erythematosus. Clin Rheumatol 2014; 34:479-88. [PMID: 25535200 DOI: 10.1007/s10067-014-2847-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 12/01/2014] [Accepted: 12/08/2014] [Indexed: 11/24/2022]
Abstract
Our aim was to determine reasons for admission, the prevalence and spectrum of infections, and the outcomes in a multiethnic cohort of hospitalized systemic lupus erythematosus (SLE) patients in Durban, South Africa. We reviewed the records of hospitalized SLE patients seen over a 79-month period; the demographic data, clinical manifestations, laboratory findings, reasons for admission, nature of infection, and outcome were recorded. Our 167 patients, comprising 59.3% Indians, 33.5% African Blacks, 5.4% Coloreds, and 1.8% Whites, had 327 admissions. Active disease and infections accounted for 218 (66.7%) and 115 (35.2%) admissions respectively, with 58 (17.7%) due to both active disease and infection. Features of active disease were mucocutaneous 33.0%, hematological 30.3%, renal 28.9%, and vasculitis 27.1%. Overall, 83 patients (49.7%) had 155 infections; pneumonia (36.8%), cutaneous sepsis (18.1%), tuberculosis (13.5%), urinary tract infections (12.9%), and septicemia (7.1%) were the most common. The organisms commonly isolated were Staphylococcus aureus 25.4%, Escherichia coli 20.3%, and Klebsiella species and Mycobacterium tuberculosis in 13.6% each. Serositis (odds ratio (OR) = 2.7, p = 0.005) and seizures (OR = 4.8, p = 0.007) were associated with increased risk of infection. Twenty-four (14.4%) patients died from infection and active disease; the patients who died had higher SLEDAI scores (p = 0.02) and longer duration of hospitalization (p = 0.03) but no significant associations on multiple logistic regression analysis. Bacterial infections, including tuberculosis, are common in SLE, and they are a major cause of mortality.
Collapse
Affiliation(s)
- Thozama Dubula
- Department of Rheumatology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal and Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | | |
Collapse
|
35
|
Luijten RKMAC, Cuppen BVJ, Bijlsma JWJ, Derksen RHWM. Serious infections in systemic lupus erythematosus with a focus on pneumococcal infections. Lupus 2014; 23:1512-6. [DOI: 10.1177/0961203314543918] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Infections are important denominators of morbidity and mortality in patients with systemic lupus erythematosus (SLE). Pneumococcus pneumoniae has been identified as a relatively frequent cause of serious infections in SLE and vaccination against this pathogen is possible. We analysed the incidence of serious infections in a cohort of SLE patients, focussing on Streptococcus pneumoniae. Methods We retrospectively screened the medical records of all SLE patients who were regularly seen in the outpatient clinic of our department between January 2010 and December 2012. We registered all infections that necessitated admission to the hospital (serious infection) and compared relevant clinical and laboratory parameters and immunomodulating/immunosuppressive treatment in patients with and without serious infections. Results In the total cohort of 260 patients, there were 132 episodes of serious infection in 70 patients, with a median follow-up per patient of 11.4 years (range 0 to 50.2 years). S. pneumoniae accounted for 11/132 (8.3%) serious infection episodes and eight of 11 episodes were invasive. With a follow-up of 3970.6 years for the total cohort, this leads to an incidence of 201/100.000 patient-years. In the multivariate analysis neither clinical parameters nor use of immunosuppressive drugs correlated with occurrence of serious infections. Conclusions Compared to the incidence of invasive pneumococcal infections in the Dutch population (15.6/100.000 patient years), the incidence in SLE patients is 13 times higher. This, in combination with the absence of a relation to use of immunosuppressive drugs, is a strong argument to recommend vaccination against S. pneumoniae in all SLE patients.
Collapse
Affiliation(s)
- R K M A C Luijten
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, The Netherlands
| | - B V J Cuppen
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, The Netherlands
| | - J W J Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, The Netherlands
| | - R H W M Derksen
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, The Netherlands
| |
Collapse
|
36
|
Chen J, Feng X, Wang H, Hua B, Ding C, Liu B, Sun L. Discriminating infectious meningitis versus neuropsychiatric involvement in patients with systemic lupus erythematosus: a single-center experience. Clin Rheumatol 2014; 34:365-9. [PMID: 24941930 DOI: 10.1007/s10067-014-2726-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 05/22/2014] [Accepted: 06/11/2014] [Indexed: 11/25/2022]
Abstract
The objective of this study is to identify the clinical differences between infectious meningitis and neuropsychiatric systemic lupus erythematosus (NPSLE) in patients with SLE. Clinical manifestations, laboratory test results, and prognoses of 14 SLE patients complicated with various infectious meningitis, hospitalized in the Affiliated Drum Tower Hospital of Nanjing University Medical School in the past 7 years, were reviewed and compared with those of 34 concomitantly treated NPSLE patients. Our study shows that mortality rate was much higher in SLE patients with infectious meningitis than in NPSLE patients. Compared to NPSLE, those with infectious meningitis had lower SLE Disease Activity Index (SLEDAI), but higher doses of corticosteroids 1 month before the occurrence of CNS symptoms. Headache, high fever, and vomiting were more common in patients with infectious meningitis, accompanied with the elevation of C-reactive protein level. Cerebrospinal fluid (CSF) examination showed increased levels of leukocytes and proteins but decreased glucose level in patients with infectious meningitis. We conclude that for SLE patients exhibiting CNS symptoms, high fever, high intake of corticosteroids, and abnormal CSF are important clues for the coexistence of infectious meningitis, especially tuberculous meningitis.
Collapse
Affiliation(s)
- Jinyun Chen
- Department of Rheumatology, The Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, 210008, China
| | | | | | | | | | | | | |
Collapse
|
37
|
Rodriguez-Pla A, Patel P, Maecker HT, Rossello-Urgell J, Baldwin N, Bennett L, Cantrell V, Baisch J, Punaro M, Gotte A, Nassi L, Wright T, Palucka AK, Banchereau J, Pascual V. IFN priming is necessary but not sufficient to turn on a migratory dendritic cell program in lupus monocytes. THE JOURNAL OF IMMUNOLOGY 2014; 192:5586-98. [PMID: 24829414 DOI: 10.4049/jimmunol.1301319] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Blood monocytes from children with systemic lupus erythematosus (SLE) behave similar to dendritic cells (DCs), and SLE serum induces healthy monocytes to differentiate into DCs in a type I IFN-dependent manner. In this study, we found that these monocytes display significant transcriptional changes, including a prominent IFN signature, compared with healthy controls. Few of those changes, however, explain DC function. Exposure to allogeneic T cells in vitro reprograms SLE monocytes to acquire DC phenotype and function, and this correlates with both IFN-inducible (IP10) and proinflammatory cytokine (IL-1β and IL6) expression. Furthermore, we found that both IFN and SLE serum induce the upregulation of CCR7 transcription in these cells. CCR7 protein expression, however, requires a second signal provided by TLR agonists such as LPS. Thus, SLE serum "primes" a subset of monocytes to readily (<24 h) respond to TLR agonists and acquire migratory DC properties. Our findings might explain how microbial infections exacerbate lupus.
Collapse
Affiliation(s)
| | - Pinakeen Patel
- Baylor Institute for Immunology Research, Dallas, TX 75204
| | - Holden T Maecker
- Human Immune Monitoring Center, Institute for Immunity, Transplantation, and Infection, Stanford University Medical Center, Stanford, CA 94305
| | | | - Nicole Baldwin
- Baylor Institute for Immunology Research, Dallas, TX 75204
| | - Lynda Bennett
- Baylor Institute for Immunology Research, Dallas, TX 75204
| | | | - Jeanine Baisch
- Baylor Institute for Immunology Research, Dallas, TX 75204
| | - Marilynn Punaro
- Division of Pediatric Rheumatology, Texas Scottish Rite Hospital for Children, Dallas, TX 75219; and University of Texas Southwestern Medical Center, Dallas, TX 75235
| | - Alisa Gotte
- Division of Pediatric Rheumatology, Texas Scottish Rite Hospital for Children, Dallas, TX 75219; and University of Texas Southwestern Medical Center, Dallas, TX 75235
| | - Lorien Nassi
- Division of Pediatric Rheumatology, Texas Scottish Rite Hospital for Children, Dallas, TX 75219; and University of Texas Southwestern Medical Center, Dallas, TX 75235
| | - Tracey Wright
- Division of Pediatric Rheumatology, Texas Scottish Rite Hospital for Children, Dallas, TX 75219; and University of Texas Southwestern Medical Center, Dallas, TX 75235
| | | | | | - Virginia Pascual
- Baylor Institute for Immunology Research, Dallas, TX 75204; Division of Pediatric Rheumatology, Texas Scottish Rite Hospital for Children, Dallas, TX 75219; and
| |
Collapse
|
38
|
Duraisingham SS, Buckland MS, Grigoriadou S, Longhurst HJ. Secondary antibody deficiency. Expert Rev Clin Immunol 2014; 10:583-91. [PMID: 24684706 DOI: 10.1586/1744666x.2014.902314] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Secondary antibody deficiencies are defined by a quantitative or qualitative decrease in antibodies that occur most commonly as a consequence of renal or gastrointestinal immunoglobulin loss, hematological malignancies and corticosteroid, immunosuppressive or anticonvulsant medications. Patients with hematological malignancies or requiring immunosuppressive medications are known to be at increased risk of infection, but few studies directly address this relationship in the context of antibody deficiency. Immunoglobulin replacement therapy has been shown to be effective in reducing infections in primary and some secondary antibody deficiencies. The commonly encountered causes of secondary antibody deficiencies and their association with infection-related morbidity and mortality are discussed. Recommendations are made for screening and clinical management of those at risk.
Collapse
Affiliation(s)
- Sai S Duraisingham
- Immunology Department, Royal London Hospital, Barts Health NHS Trust, London, UK
| | | | | | | |
Collapse
|
39
|
Caza T, Oaks Z, Perl A. Interplay of Infections, Autoimmunity, and Immunosuppression in Systemic Lupus Erythematosus. Int Rev Immunol 2014; 33:330-63. [DOI: 10.3109/08830185.2013.863305] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
40
|
Costa-Reis P, Nativ S, Isgro J, Rodrigues T, Yildirim-Toruner C, Starr A, Saiman L, Imundo L, Eichenfield A. Major infections in a cohort of 120 patients with juvenile-onset systemic lupus erythematosus. Clin Immunol 2013; 149:442-9. [DOI: 10.1016/j.clim.2013.08.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 08/22/2013] [Accepted: 08/24/2013] [Indexed: 11/30/2022]
|
41
|
Migita K, Arai T, Ishizuka N, Jiuchi Y, Sasaki Y, Izumi Y, Kiyokawa T, Suematsu E, Miyamura T, Tsutani H, Kawabe Y, Matsumura R, Mori S, Ohshima S, Yoshizawa S, Kawakami K, Suenaga Y, Nishimura H, Sugimoto T, Iwase H, Sawada H, Yamashita H, Kuratsu S, Ogushi F, Kawabata M, Matsui T, Furukawa H, Bito S, Tohma S. Rates of serious intracellular infections in autoimmune disease patients receiving initial glucocorticoid therapy. PLoS One 2013; 8:e78699. [PMID: 24260127 PMCID: PMC3834005 DOI: 10.1371/journal.pone.0078699] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 09/14/2013] [Indexed: 11/27/2022] Open
Abstract
Background/Aims The Japanese National Hospital Organization evidence-based medicine (EBM) Study group for Adverse effects of Corticosteroid therapy (J-NHOSAC) is a Japanese hospital-based cohort study investigating the safety of the initial use of glucocorticoids (GCs) in patients with newly diagnosed autoimmune diseases. Using the J-NHOSAC registry, the purpose of this observational study is to analyse the rates, characteristics and associated risk factors of intracellular infections in patients with newly diagnosed autoimmune diseases who were initially treated with GCs. Methodology/Principal Findings A total 604 patients with newly diagnosed autoimmune diseases treated with GCs were enrolled in this registry between April 2007 and March 2009. Cox proportional-hazards regression was used to determine independent risk factors for serious intracellular infections with covariates including sex, age, co-morbidity, laboratory data, use of immunosuppressants and dose of GCs. Survival was analysed according to the Kaplan-Meier method and was assessed by the log-rank test. There were 127 serious infections, including 43 intracellular infections, during 1105.8 patient-years of follow-up. The 43 serious intracellular infections resulted in 8 deaths. After adjustment for covariates, diabetes (Odds ratio [OR]: 2.5, 95% confidence interval [95% CI] 1.1–5.9), lymphocytopenia (≦1000/μl, OR: 2.5, 95% CI 1.2–5.2) and use of high-dose (≧30 mg/day) GCs (OR: 2.4, 95% CI 1.1–5.3) increased the risk of intracellular infections. Survival curves showed lower intracellular infection-free survival rate in patients with diabetes, lymphocytopaenia and high-dose GCs treatments. Conclusions/Significance Patients with newly diagnosed autoimmune diseases were at high risk of developing intracellular infection during initial treatment with GCs. Our findings provide background data on the risk of intracellular infections of patients with autoimmune diseases. Clinicians showed remain vigilant for intracellular infections in patients with autoimmune diseases who are treated with GCs.
Collapse
Affiliation(s)
- Kiyoshi Migita
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
- * E-mail:
| | - Toru Arai
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Naoki Ishizuka
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Yuka Jiuchi
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Yasuharu Sasaki
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Yasumori Izumi
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Tetsuyuki Kiyokawa
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Eiichi Suematsu
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Tomoya Miyamura
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Hiroshi Tsutani
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Yojiro Kawabe
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Ryutaro Matsumura
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Shunsuke Mori
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Shiro Ohshima
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Shigeru Yoshizawa
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Kenji Kawakami
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Yasuo Suenaga
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Hideo Nishimura
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Toyohiko Sugimoto
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Hiroaki Iwase
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Hideyuki Sawada
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Haruhiro Yamashita
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Shigeyuki Kuratsu
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Fumitaka Ogushi
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Masaharu Kawabata
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Toshihiro Matsui
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Hiroshi Furukawa
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Seiji Bito
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| | - Shigeto Tohma
- Japanese National Hospital Organization (NHO)-EBM study group for Adverse Effects of Corticosteroid Therapy (J-NHOSAC), Meguro, Tokyo, Japan
| |
Collapse
|
42
|
Barber C, Lacaille D, Fortin PR. Systematic review of validation studies of the use of administrative data to identify serious infections. Arthritis Care Res (Hoboken) 2013; 65:1343-57. [PMID: 23335588 DOI: 10.1002/acr.21959] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 01/10/2013] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To conduct a systematic review of the literature on the validation of algorithms identifying infections in administrative data for future use in populations with rheumatic diseases. METHODS Medline and EMBase were searched using the themes "administrative data" and "infection" between 1950 and October 2012. Inclusion criteria consisted of validation studies of administrative data identifying infections in adult populations. Article quality was assessed using a validated tool. RESULTS A total of 5,941 articles were identified, 90 articles underwent detailed review, and 24 studies were included. The majority (17 of 24) examined bacterial infections and 9 examined opportunistic infections. Eighteen studies were from the US and all but 4 studies used International Classification of Diseases, Ninth Revision codes. Rheumatoid arthritis patients were studied in 6 of 24 articles. The studies on bacterial infections in general reported highly variable sensitivity and positive predictive value (PPV) for the diagnosis of infections using administrative data (sensitivity range 4.4-100%, PPV range 21.7-100%). Algorithms to identify opportunistic infections similarly had a highly variable sensitivity (range 20-100%) and PPV (range 1.3-100%). Thirteen studies compared the diagnostic accuracy of different algorithms, which revealed that strategies including a comprehensive algorithm using a greater number of diagnostic codes or codes in any position had the highest sensitivity for the diagnosis of infection. Algorithms that incorporated microbiologic or pharmacy data in combination with diagnostic codes had improved PPV for identification of tuberculosis. CONCLUSION Algorithms for identifying infections using administrative data should be selected based on the purpose of the study, with careful consideration as to whether a high sensitivity or PPV is required.
Collapse
Affiliation(s)
- Claire Barber
- University Health Network, Toronto Western Research Institute, and University of Toronto, Toronto, Ontario, Canada
| | | | | |
Collapse
|
43
|
Danza A, Ruiz-Irastorza G. Infection risk in systemic lupus erythematosus patients: susceptibility factors and preventive strategies. Lupus 2013; 22:1286-94. [DOI: 10.1177/0961203313493032] [Citation(s) in RCA: 224] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Infection is one of the leading causes of morbidity and mortality in systemic lupus erythematosus (SLE). Bacterial infections are most frequent, followed by viral and fungal infections. The impaired cellular and humoral immune functions seen in patients with SLE are predisposing conditions, whilst disease activity, prednisone doses over 7.5–10 mg/day, high doses of methylprednisolone or cyclophosphamide are well-recognised risk factors for infection. The first six months after rituximab treatment and the use of more than three courses are also associated with an increased susceptibility for infection. It has not been established whether belimumab, azathioprine and mycophenolate mofetil increase the risk of serious infections. Most vaccines are effective and safe in SLE patients, although vaccination should be avoided during periods of active disease. Live virus vaccines are contraindicated for immunosuppressed patients. Influenza and pneumococcal vaccines are universally recommended. Tuberculosis prophylaxis should be considered in selected cases. Therefore, it is advisable not to exceed doses of 5 mg/day of prednisone in chronic treatment. Methylprednisolone and cyclophosphamide should be used in low-dose regimens. Antimalarials have a well-known protective role against infection, in addition to other beneficial properties, thus, hydroxychloroquine is recommended for all SLE patients where no contraindication exists.
Collapse
Affiliation(s)
- A Danza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Hospital De Cruces, University of the Basque Country, Spain
- Clinical Department of Medicine, Facultad de Medicina, Universidad de la República, Uruguay
| | - G Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Hospital De Cruces, University of the Basque Country, Spain
| |
Collapse
|
44
|
Sciascia S, Cuadrado MJ, Karim MY. Management of infection in systemic lupus erythematosus. Best Pract Res Clin Rheumatol 2013; 27:377-89. [DOI: 10.1016/j.berh.2013.07.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
|
45
|
Rozenblyum EV, Allen UD, Silverman ED, Levy DM. Cytomegalovirus infection in childhood-onset systemic lupus erythematosus. INTERNATIONAL JOURNAL OF CLINICAL RHEUMATOLOGY 2013; 8:137-146. [PMID: 24527062 PMCID: PMC3920748 DOI: 10.2217/ijr.12.82] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Systemic lupus erythematosus (SLE) is a multisystem disease with significant morbidity and even mortality. Cytomegalovirus (CMV) is a ubiquitous herpesvirus that, similar to SLE, can also lead to significant morbidity and mortality in the immunocompromised host. The relationship between SLE and CMV is complex, with observations suggesting that CMV induces the autoimmunity of SLE in addition to occurring in the immunocompromised host with known SLE. In this article, we first consider CMV infection in the immunocompetent host, and further examine how this infection differs in the patient with SLE. We focus on disease mechanisms, CMV detection and treatment. We review the differences between CMV infection, syndrome and disease, as identifying the correct state will determine the appropriate treatment. We propose guidelines for the screening and management of CMV infection in childhood-onset SLE, and recognize that further study in this population is required to increase our understanding of the interplay between these disease entities.
Collapse
Affiliation(s)
- Evelyn V Rozenblyum
- Department of Pediatrics, Hospital for Sick Children & University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Upton D Allen
- Department of Pediatrics, Hospital for Sick Children & University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Division of Infectious Diseases, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Earl D Silverman
- Department of Pediatrics, Hospital for Sick Children & University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Division of Rheumatology, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Deborah M Levy
- Department of Pediatrics, Hospital for Sick Children & University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Division of Rheumatology, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| |
Collapse
|
46
|
Arenas Miras MDM, Hidalgo Tenorio C, Jimenez Alonso J. Tuberculosis in patients with systemic lupus erythematosus: Spain's situation. ACTA ACUST UNITED AC 2012; 9:369-72. [PMID: 23102827 DOI: 10.1016/j.reuma.2012.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Revised: 06/13/2012] [Accepted: 06/21/2012] [Indexed: 11/18/2022]
Abstract
There has recently been an increase in the incidence of patients with systemic lupus erythematosus (SLE) due mainly to earlier diagnosis, and increased survival. Tuberculosis in our country is one of the most prevalent infectious diseases, and one of the underlying causes would be HIV infection and increased immigration from areas with high tuberculosis prevalence; this phenomenon is truly important in patients with autoimmune diseases, as clinical presentation, severity and prognosis of tuberculosis are often different to that of immunocompetent patients. Studies of tuberculosis in patients with SLE are scarce and inconclusive, with many doubts existing about the performance or non-tuberculous prophylaxis in this population and the absence of a protocol due to lack of conclusive studies. New techniques for diagnosis of tuberculosis (IGRAs) may be useful in this population due to higher sensitivity than Mantoux, helping avoid false negatives.
Collapse
|
47
|
Fujimoto D, Matsushima A, Nagao M, Takakura S, Ichiyama S. Risk factors associated with elevated blood cytomegalovirus pp65 antigen levels in patients with autoimmune diseases. Mod Rheumatol 2012; 23:345-50. [PMID: 22534885 DOI: 10.1007/s10165-012-0651-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 04/03/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVES To further assess the relationship between elevated levels of cytomegalovirus (CMV) pp65 antigen in blood, as indicative of viral load, during treatment-free follow-up and CMV diseases in patients with autoimmune diseases and to identify any risk factors associated with elevated viral loads. METHODS This was a retrospective review of the electronic medical charts of 148 patients with autoimmune diseases who tested positive for CMV pp65 antigen in the blood. RESULTS A total of 106 patients were analyzed. During follow-up, elevated viral loads were detected in 35 patients who were not on antiviral therapy, of whom five developed CMV diseases. Elevated viral load was significantly associated with CMV diseases [5/35 vs. 0/71 (no elevated viral load); P = 0.001). Multivariate analysis revealed that lymphopenia [lymphocyte numbers <700/mm(3), odds ratio (OR) 34.44, 95 % confidence interval (CI), 7.82-151.66; P < 0.001], systemic lupus erythematosus (SLE) (OR 6.71, 95 % CI, 1.23-36.49; P = 0.028), and polymyositis/dermatomyositis (PM/DM) (OR 10.62, 95 % CI 1.41-79.77; P = 0.022) were significantly associated with elevated viral load. CONCLUSIONS Elevated viral load was significantly associated with CMV diseases. Patients with SLE or PM/DM and lymphopenia would therefore benefit from a detailed viral load follow-up and careful physical examination.
Collapse
Affiliation(s)
- Daichi Fujimoto
- Department of Infection Control and Prevention, Kyoto University Hospital, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, Kyoto 606-8507, Japan
| | | | | | | | | |
Collapse
|
48
|
Lyrio LDC, Grassi MFR, Santana IU, Olavarria VG, Gomes ADN, CostaPinto L, Oliveira RPC, Aquino RDCR, Santiago MB. Prevalence of cervical human papillomavirus infection in women with systemic lupus erythematosus. Rheumatol Int 2012; 33:335-40. [DOI: 10.1007/s00296-012-2426-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Accepted: 03/11/2012] [Indexed: 11/24/2022]
|