Association of herpes zoster infection with clinical characteristics and MBL2 gene polymorphisms in Chinese children with systemic lupus erythematosus

Herpes zoster in SLE: prevalence, incidence and risk factors

Objectives

This study aimed to evaluate the prevalence and incidence of herpes zoster (HZ) events and describe its associated factors in a study of patients with SLE.

Methods

491 consecutive SLE participants were screened for HZ events using a patient-reported questionnaire to capture outcomes on pain and other characteristics associated with HZ events. Sociodemographic, clinical and laboratory measures were also analysed, and time-dependent Cox regression survival analyses were performed to investigate factors associated with HZ events.

Results

Prevalence of HZ was 30.5%, incidence was 14.3 cases per 1000 person-years. Lymphopenia and glucocorticoid dosing were significantly associated with HZ events.

Conclusions

HZ is highly prevalent in SLE, which may be linked to disease-related and treatment-related effects on cellular immunity. Our results suggest that the presence of certain risk factors may be useful to allow identification of patients at risk of HZ and improve its management in patients with SLE.

2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases

To update the European League Against Rheumatism (EULAR) recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases (AIIRD) published in 2011. Four systematic literature reviews were performed regarding the incidence/prevalence of vaccine-preventable infections among patients with AIIRD; efficacy, immunogenicity and safety of vaccines; effect of anti-rheumatic drugs on the response to vaccines; effect of vaccination of household of AIIRDs patients. Subsequently, recommendations were formulated based on the evidence and expert opinion. The updated recommendations comprise six overarching principles and nine recommendations. The former address the need for an annual vaccination status assessment, shared decision-making and timing of vaccination, favouring vaccination during quiescent disease, preferably prior to the initiation of immunosuppression. Non-live vaccines can be safely provided to AIIRD patients regardless of underlying therapy, whereas live-attenuated vaccines may be considered with caution. Influenza and pneumococcal vaccination should be strongly considered for the majority of patients with AIIRD. Tetanus toxoid and human papilloma virus vaccination should be provided to AIIRD patients as recommended for the general population. Hepatitis A, hepatitis B and herpes zoster vaccination should be administered to AIIRD patients at risk. Immunocompetent household members of patients with AIIRD should receive vaccines according to national guidelines, except for the oral poliomyelitis vaccine. Live-attenuated vaccines should be avoided during the first 6 months of life in newborns of mothers treated with biologics during the second half of pregnancy. These 2019 EULAR recommendations provide an up-to-date guidance on the management of vaccinations in patients with AIIRD.

Herpes zoster in patients with systemic lupus erythematosus: Clinical features, complications and risk factors

Herpes Zoster (HZ) is reported as the most prevalent viral infection in patients with systemic lupus erythematosus (SLE). The aim of the present study was to investigate the clinical features, complications, and potential risk factors of HZ in patients with SLE from Southern China. A retrospective study was performed among patients with SLE admitted to the First Affiliated Hospital of Sun Yet-Sen University (Guangzhou, China) between 2009 and 2013. Demographic information, clinical and laboratory data, and medications used were collected and analyzed. A total of 48 instances of HZ from 46 individuals in a cohort of 1,265 SLE patients during the follow-up period were identified, with an overall prevalence of 3.6%. Complications occurred in 23.9% of patients with HZ (11/46). The risk of HZ was highest within 3-6 months following SLE diagnosis and reduced thereafter. The multivariate logistic regression analysis demonstrated that lymphopenia (OR=4.6; 95% CI=1.5-13.8; P=0.006) and treatment with high-dose glucocorticoids (GC; OR=4.3; 95% CI=1.6-11.7; P=0.004) were both significantly associated with occurrence of HZ. Lymphopenia was the only independent risk factor for the occurrence of complicated HZ (OR=15.2; 95% CI=2.7-85.1; P=0.002). There are some notable characteristics of HZ in patients with SLE in Southern China, such as the tendency to manifest in an early stage of SLE, and frequent complications with benign outcomes. The present data supported the role of lymphopenia and high-dose of GC therapy as risk factors for the occurrence of HZ. Lymphopenia was also shown to contribute to complicated HZ.

Immunosuppressive medication use and risk of herpes zoster (HZ) in patients with systemic lupus erythematosus (SLE): A nationwide case-control study

BACKGROUND

The association between immunosuppressive medication use and herpes zoster (HZ) in patients with systemic lupus erythematosus (SLE) has not been clearly defined.

OBJECTIVE

We evaluated the risk of HZ in patients with SLE treated with different immunosuppressants.

METHODS

A nationwide population-based case-control study was conducted using the Taiwanese National Health Insurance Research Database. Cases (1555 patients with SLE who developed HZ) and controls (3049 age- and sex-matched patients with SLE but without HZ) were analyzed for use of various immunosuppressive medications in the preceding 3-month period, and dose-response relationships were determined. Logistic regression was performed to estimate the adjusted odds ratio for HZ development.

RESULTS

Medications associated with greater HZ risk in patients with SLE included oral corticosteroids, intravenous methylprednisolone, hydroxychloroquine, oral cyclophosphamide, intravenous cyclophosphamide, azathioprine, methotrexate, and mycophenolate mofetil. Combination immunosuppressive therapy was common in patients with SLE and was associated with greatly increased HZ risk. For oral corticosteroids and hydroxychloroquine, the risk of HZ was strongly dependent on the medication dose.

LIMITATIONS

This study is retrospective in nature.

CONCLUSION

Recent immunosuppressive medication use is associated with increased HZ risk in patients with SLE, particularly those receiving high-dose oral corticosteroids and multiagent immunosuppressive therapy.

Persistent improper upregulation of Th17 and TReg cells in patients with juvenile idiopathic arthritis

OBJECTIVES

Juvenile idiopathic arthritis (JIA) is the most common childhood rheumatic disease. A break in the balance between Th17 and TReg cells has been reported as an important factor in the development of autoimmune diseases. This study aimed to analyze peripheral Th17 and TReg cell levels in patients with JIA.

METHODS

The balance of Th17 and TReg cells among active and inactive JIA patients and normal control subjects were compared. Human peripheral blood mononuclear cells were isolated from the patients and controls. Surface and intracellular staining for CD4, CD25, Foxp3, IL-17, Th17, and TReg were analyzed.

RESULTS

Twenty-eight JIA patients, including 12 with active JIA and 16 with inactive JIA, and 20 health controls were analyzed. Patients with active JIA had higher Th17 (1.85 ± 1.15 vs. 1.05 ± 0.72, p = 0.008) and TReg cells (1.1 ± 0.8 vs. 0.6 ± 0.7, p = 0.04) levels than those with inactive JIA. Among active JIA patients, remission days were highly correlated with the CD4(+)IL17A(+) T cell percentage, 276.5 ± 137.40 days (range, 130 ∼ 525 days), p < 0.01. There were no differences in Th17/TReg percentage between JIA patients and controls in the peripheral blood.

CONCLUSIONS

Th17 and TReg cell levels are elevated in patients with active JIA and there is no Th17/TReg imbalance. The higher Th17 level predicted longer period to reach disease inactive stage. Improper Th17 up-regulation might contribute to JIA activation.

Diagnosis and management of infectious complications of childhood rheumatic diseases

Progress in the diagnosis and management of pediatric rheumatic disease has improved complications from underlying disease and the survival of children. However, as a consequence, infection has now become one of the leading causes of morbidity and mortality. Differentiating between infections and disease flares in children with rheumatic conditions can often pose diagnostic quandaries. Children with rheumatic diseases are at risk of infection, not only because of the use of immune-modulating medications but also because of underlying immune dysfunction associated with their disease. Although bacterial infections are the most common, any organism can potentially be a causative agent and, at times, more invasive measures of diagnosis, for example bronchoscopy and tissue biopsies may be necessary. Maintaining a high index of suspicion of infection with prompt diagnosis and treatment are important to further improve patient outcomes.