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Gil-Rodríguez J, Fernández JDLH, Ruiz MM, Fernández RR, Morales MG, Callejas-Rubio JL. Nocardiosis in systemic lupus erythematosus patients treated with rituximab: Report of two cases and systematic review of literature. Lupus 2025; 34:316-325. [PMID: 40013520 DOI: 10.1177/09612033251319836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2025]
Abstract
BackgroundThe relationship between systemic lupus erythematosus (SLE) patients treated with rituximab and nocardiosis remains unclear.Cases ReportA 55-year-old female with lupus nephritis II and smoking history, was treated with high-dose steroids, immunoglobulins, rituximab, and azathioprine. She developed infectious loci in the lungs, hip, and brain. N. farcinica was detected in bronchoalveolar lavage and abscess culture. She was treated with linezolid, trimethoprim/sulfamethoxazole (TMP/SMX), minocycline, and amoxicillin/clavulanic acid, achieving complete cure at 12 months. The second patient, a 73-year-old male with lupus nephritis V, autoimmune thrombocytopenia, antiphospholipid syndrome (APS), and alveolar hemorrhage, was treated with high-dose steroids, azathioprine, mycophenolate, and rituximab. He developed infections in the lungs, prostate, and possibly colon. N. farcinica was detected in blood cultures. Despite treatment with imipenem, linezolid, TMP/SMX, and moxifloxacin, he died from bronchoaspiration.MethodsA systematic review was conducted using PubMed, Embase, Web of Science, and Scopus. The search terms were (systemic lupus erythematosus OR SLE) AND (rituximab) AND (nocardia), with a timeframe up to 15 March 2024. Inclusion criteria were confirmed cases of Nocardia infection in SLE patients treated with rituximab in the previous year. Non-original studies and secondary research were excluded.ResultsOnly one article was included, describing a 34-year-old male with APS and lupus nephritis IV, treated with high-dose steroids, cyclophosphamide, and rituximab. He had infections in the lungs and brain, with N. farcinica detected in blood cultures. Despite treatment with TMP/SMX and fluoroquinolones, he died from thrombotic complications.ConclusionNocardiosis is more likely in SLE patients due to T lymphocyte immune dysfunction caused by the disease itself, rituximab, and other immunosuppressants. Diagnosis requires a high level of clinical suspicion, supported by long-time blood cultures and 16S rRNA. Beta-lactams and quinolones are reasonable alternatives to TMP/SMX and linezolid, which can worsen the hematological situation, and amikacin, which may worsen lupus nephritis.
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Affiliation(s)
- Jaime Gil-Rodríguez
- Departamento de Medicina Interna, Hospital Universitario Clínico San Cecilio, Granada, España
| | - Javier de la Hera Fernández
- Unidad de Enfermedades Autoinmunes Sistémicas, Hospital Universitario Clínico San Cecilio, Granada, España
- Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, España
| | - Michel Martos Ruiz
- Departamento de Medicina Interna, Hospital Universitario Clínico San Cecilio, Granada, España
| | - Raquel Ríos Fernández
- Unidad de Enfermedades Autoinmunes Sistémicas, Hospital Universitario Clínico San Cecilio, Granada, España
- Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, España
| | - Marta García Morales
- Unidad de Enfermedades Autoinmunes Sistémicas, Hospital Universitario Clínico San Cecilio, Granada, España
- Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, España
| | - José-Luis Callejas-Rubio
- Unidad de Enfermedades Autoinmunes Sistémicas, Hospital Universitario Clínico San Cecilio, Granada, España
- Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, España
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Passerini M, Nayfeh T, Yetmar ZA, Coussement J, Goodlet KJ, Lebeaux D, Gori A, Mahmood M, Temesgen Z, Murad MH. Trimethoprim-sulfamethoxazole significantly reduces the risk of nocardiosis in solid organ transplant recipients: systematic review and individual patient data meta-analysis. Clin Microbiol Infect 2024; 30:170-177. [PMID: 37865337 DOI: 10.1016/j.cmi.2023.10.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/06/2023] [Accepted: 10/08/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND Whether trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis prevents nocardiosis in solid organ transplant (SOT) recipients is controversial. OBJECTIVES To assess the effect of TMP-SMX in the prevention of nocardiosis after SOT, its dose-response relationship, its effect on preventing disseminated nocardiosis, and the risk of TMP-SMX resistance in case of breakthrough infection. METHODS A systematic review and individual patient data meta-analysis. DATA SOURCES MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Web of Science Core Collection, and Scopus up to 19 September 2023. STUDY ELIGIBILITY CRITERIA (a) Risk of nocardiosis between SOT recipients with and without TMP-SMX prophylaxis, or (b) sufficient details to determine the rate of TMP-SMX resistance in breakthrough nocardiosis. PARTICIPANTS SOT recipients. INTERVENTION TMP-SMX prophylaxis versus no prophylaxis. ASSESSMENT OF RISK OF BIAS Risk Of Bias In Non-randomized Studies-of Exposure (ROBINS-E) for comparative studies; dedicated tool for non-comparative studies. METHODS OF DATA SYNTHESIS For our primary outcome (i.e. to determine the effect of TMP-SMX on the risk of nocardiosis), a one-step mixed-effects regression model was used to estimate the association between the outcome and the exposure. Univariate and multivariable unconditional regression models were used to adjust for the potential confounding effects. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS Individual data from three case-control studies were obtained (260 SOT recipients with nocardiosis and 519 uninfected controls). TMP-SMX prophylaxis was independently associated with a significantly decreased risk of nocardiosis (adjusted OR = 0.3, 95% CI 0.18-0.52, moderate certainty of evidence). Variables independently associated with an increased risk of nocardiosis were older age, current use of corticosteroids, high calcineurin inhibitor concentration, recent acute rejection, lower lymphocyte count, and heart transplant. Breakthrough infections (66/260, 25%) were generally susceptible to TMP-SMX (pooled proportion 98%, 95% CI 92-100). CONCLUSIONS In SOT recipients, TMP-SMX prophylaxis likely reduces the risk of nocardiosis. Resistance appears uncommon in case of breakthrough infection.
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Affiliation(s)
- Matteo Passerini
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy; Department of Infectious Disease, ASST FBF SACCO Fatebenefratelli, Milan, Lombardia, Italy.
| | - Tarek Nayfeh
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Zachary A Yetmar
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Department of Infectious Diseases, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Julien Coussement
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia; Service de Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire de Guadeloupe, Les Abymes, Guadeloupe, France
| | - Kellie J Goodlet
- Department of Pharmacy Practice, Midwestern University, Glendale, AZ, USA; Norton Thoracic Institute, Dignity Health - St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - David Lebeaux
- Institut Pasteur, Université Paris Cité, CNRS UMR 6047, Genetics of Biofilms Laboratory, Paris, France; Département de Maladies Infectieuses et Tropicales, AP-HP, Hôpital Saint-Louis, Lariboisière, Paris, France
| | - Andrea Gori
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy; Department of Infectious Disease, ASST FBF SACCO Fatebenefratelli, Milan, Lombardia, Italy; Centre for Multidisciplinary Research in Health Science (MACH), University of Milan, Milan, Italy
| | - Maryam Mahmood
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Zelalem Temesgen
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mohammad H Murad
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Carver CA, Kalesinskas M, Ahmed AR. Current biologics in treatment of pemphigus foliaceus: a systematic review. Front Immunol 2023; 14:1267668. [PMID: 37901249 PMCID: PMC10600482 DOI: 10.3389/fimmu.2023.1267668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 09/26/2023] [Indexed: 10/31/2023] Open
Abstract
Background Pemphigus foliaceus (PF) differs from pemphigus vulgaris (PV) in that it affects only the skin and mucous membranes are not involved. Pemphigus is commonly treated with systemic corticosteroids and immunosuppressive agents (ISAs). More recently, biologics have been used. The current literature on biologic therapy often combines treatment of PF with PV, hence it is often difficult for clinicians to isolate the treatment of PF from PV. The purpose of this review was to provide information regarding the use of current biological therapy, specifically in PF. Materials and methods A search of PubMed, Embase, and other databases was conducted using keywords pemphigus foliaceus (PF), rituximab (RTX), intravenous immunoglobulin (IVIg), and biologics. Forty-one studies were included in this review, which produced 105 patients with PF, treated with RTX, IVIg, or a combination of both. Eighty-five patients were treated with RTX, eight patients with IVIg, and 12 received both RTX and IVIg. Results Most patients in this review had PF that was nonresponsive to conventional immunosuppressive therapies (CIST), and had significant side effects from their use. RTX treatment resulted in complete remission (CR) in 63.2%, a relapse rate of 39.5%, an infection rate of 19.7%, and a mortality rate of 3.9%. Relapse was greater in the lymphoma (LP) protocol than the rheumatoid arthritis (RA) protocol (p<0.0001). IVIg led to CR in 62.5% of patients, with no relapses or infections. Patients receiving both biologics experienced better outcomes when RTX was first administered, then followed by IVIg. Follow-up durations for patients receiving RTX, IVIg, and both were 22.1, 24.8, and 35.7 months, respectively. Discussion In pemphigus foliaceus patients nonresponsive to conventional immunosuppressive therapy or in those with significant side effects from CIST, RTX and IVIg appear to be useful agents. Profile of clinical response, as well as relapse, infection, and mortality rates in PF patients treated with RTX were similar to those observed in PV patients. The data suggests that protocols specific for PF may produce better outcomes, less adverse effects, and improved quality of life.
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Affiliation(s)
- Caden A. Carver
- Midwestern University, Arizona College of Osteopathic Medicine, Glendale, AZ, United States
| | - Mikole Kalesinskas
- Department of Dermatology, Center for Blistering Disease, Tufts University School of Medicine, Boston, MA, United States
| | - A. Razzaque Ahmed
- Department of Dermatology, Center for Blistering Disease, Tufts University School of Medicine, Boston, MA, United States
- Department of Dermatology, Tufts University School of Medicine, Boston, MA, United States
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