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Cao B, Robinson JE, Winget M, Hunt MH, Carlson R, Hogan SL, Derebail VK, Thorpe CT. Infection prophylaxis among patients with antineutrophil cytoplasmic antibody (ANCA) vasculitis: a scoping review. Clin Rheumatol 2024; 43:2765-2781. [PMID: 39058400 DOI: 10.1007/s10067-024-07074-4] [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: 06/10/2024] [Revised: 07/08/2024] [Accepted: 07/14/2024] [Indexed: 07/28/2024]
Abstract
Severe infections associated with the use of strong immunosuppressive medication are a leading cause of morbidity and mortality in patients with ANCA vasculitis (AV). While guidelines conditionally recommend trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis for Pneumocystis jirovecii pneumonia in AV patients, robust evidence on prophylaxis strategies is lacking. This scoping review aimed to assess the existing evidence on infection prophylaxis in AV patients, identify knowledge gaps, and guide future study design. A comprehensive search of six databases and relevant references identified original studies in English from January 1, 2000, to July 31, 2020. Inclusion criteria encompassed studies evaluating the impact of any antimicrobial prophylaxis strategy on infection-related outcomes in AV patients receiving immunosuppressive treatment. Studies were screened by four researchers using a blinded approach. Data was extracted by two reviewers, with differences resolved via consensus in consultation with a third reviewer. Nineteen studies met inclusion criteria, including two randomized trials and 17 cohort studies, with TMP-SMX being the most commonly assessed prophylactic strategy. The studies varied in sample sizes, outcomes measured, prophylactic strategies employed, and proportion of patients who received the regimen. Most cohort studies included no or limited control of potential confounding factors. This scoping review suggests significant variation in AV patients' receipt of TMP-SMX and alternative infection prophylaxis approaches. Observational studies using large secondary healthcare databases with rigorous designs are needed to provide high-quality evidence of the real-world effectiveness of antimicrobial prophylactic regimens, to improve clinical decision-making and quality of care for AV patients receiving immunosuppressive treatment.
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Affiliation(s)
- Binxin Cao
- University of North Carolina Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, USA.
| | - Jacob E Robinson
- University of North Carolina Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, USA
| | - Marshall Winget
- University of North Carolina Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, USA
| | - Madison H Hunt
- University of North Carolina Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, USA
| | - Rebecca Carlson
- University of North Carolina Health Sciences Library, 335 S. Columbia Street, Chapel Hill, NC, 27599, USA
| | - Susan L Hogan
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, USA
| | - Vimal K Derebail
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, USA
| | - Carolyn T Thorpe
- University of North Carolina Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive (151C), Building 30, Pittsburgh, PA, 15240-1001, USA
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Tumba MC, Silva RL, Arevalo AB, Sattui SE. Current perspective on infections and mitigation strategies in primary systemic vasculitis. Curr Rheumatol Rep 2024; 26:279-289. [PMID: 38668813 DOI: 10.1007/s11926-024-01149-6] [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] [Accepted: 04/18/2024] [Indexed: 07/05/2024]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize and evaluate most recent evidence on the epidemiology of infections and associated risk factors in patients with primary systemic vasculitides (PSV), as well as discuss mitigation strategies including the risk of antibiotic prophylaxis. RECENT FINDINGS Infections remain one of the leading causes of mortality in patients with PSV, with rates of severe infection ranging from 16 to 40% in different cohorts. Older age, frailty, renal and pulmonary involvement, and higher burden of comorbidities have been recognized as important patient-associated risk factors. Treatments including higher cumulative doses of glucocorticoids are associated with an increased risk of infections, and recent studies show the potential benefit of interventions such as reduced-dose glucocorticoid regimens. Existing mitigation strategies include screening, vaccination, and infection prophylaxis. The latter remains particularly important for Pneumocystis jirovecii pneumonia; however, the benefit-risk ratio seems to be less clear outside of induction phase (i.e., high dose of glucocorticoids) and optimal treatment duration remains less clear. Patients with PSV are at increased risk of infections, due to disease itself, comorbidities, and treatment side effects. Awareness of the timing and types of infection, as well as mitigation strategies are imperative to ensure treatment success and survival for patients.
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Affiliation(s)
- Manuel Carpio Tumba
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Raisa Lomanto Silva
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ana B Arevalo
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Massachusetts, Boston, MA, USA
| | - Sebastian E Sattui
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, PA, USA.
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Iwashige Y, Yamamoto S, Ohue K, Sugimoto H, Yabumoto H, Kamimatsuse R, Kamido H, Akagi R, Matsumoto M, Yamamoto-Nonaka K, Minamiguchi S, Yanagita M. A Rare Case of Drug Reaction with Eosinophilia and Systemic Symptoms Syndrome Leading to Hemodialysis and Multiple Infections: A Case Report and Literature Review. Intern Med 2024; 63:1131-1138. [PMID: 37612089 PMCID: PMC11081887 DOI: 10.2169/internalmedicine.1959-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 07/13/2023] [Indexed: 08/25/2023] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe drug eruption that causes multiple organ damage. The renal impairment in these patients usually improves with immunosuppressants, but subsequent infections often develop. We herein report a rare case of DRESS syndrome leading to hemodialysis and multiple infections with Pneumocystis pneumonia, cytomegalovirus and Aspergillus despite the administration of low-dose prednisolone. We also present a literature review of cases requiring dialysis after DRESS syndrome. In patients with chronic kidney disease, it is important to be alert for not only the development of DRESS syndrome but also subsequent infections.
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Affiliation(s)
| | | | - Kaoru Ohue
- Department of Nephrology, Kyoto University, Japan
| | | | | | | | | | - Ryota Akagi
- Department of Nephrology, Kyoto University, Japan
| | | | | | | | - Motoko Yanagita
- Department of Nephrology, Kyoto University, Japan
- Institute for the Advanced Study of Human Biology (WPI-ASHBi), Kyoto University, Japan
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Chastain DB, Spradlin M, Ahmad H, Henao-Martínez AF. Unintended Consequences: Risk of Opportunistic Infections Associated With Long-term Glucocorticoid Therapies in Adults. Clin Infect Dis 2024; 78:e37-e56. [PMID: 37669916 DOI: 10.1093/cid/ciad474] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Indexed: 09/07/2023] Open
Abstract
Glucocorticoids are widespread anti-inflammatory medications used in medical practice. The immunosuppressive effects of systemic glucocorticoids and increased susceptibility to infections are widely appreciated. However, the dose-dependent model frequently used may not accurately predict the risk of infection in all patients treated with long-term glucocorticoids. In this review, we examine the risks of opportunistic infections (OIs) in patients requiring glucocorticoid therapy by evaluating the influence of the glucocorticoid dose, duration, and potency, combined with biological and host clinical factors and concomitant immunosuppressive therapy. We propose strategies to prevent OIs, which involve screening, antimicrobial prophylaxis, and immunizations. While this review focuses on patients with autoimmune, inflammatory, or neoplastic diseases, the potential risks and preventative strategies are likely applicable to other populations. Clinicians should actively assess the benefit-harm ratios of systemic glucocorticoids and implement preventive efforts to decrease their associated infections complications.
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Affiliation(s)
- Daniel B Chastain
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, Georgia, USA
| | - Megan Spradlin
- Division of Medical Oncology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Hiba Ahmad
- Division of Medical Oncology, University of Colorado School of Medicine, Aurora, Colorado, USA
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Zhou W, Chen H, Ji T, Chen R, Xu Q, Chen L, Cao M, Cai H, Dai J. Prognostic factors of fungal infection in anti-melanoma differentiation-associated gene 5 antibody-positive associated interstitial lung disease. Clin Rheumatol 2024; 43:1381-1392. [PMID: 38345696 DOI: 10.1007/s10067-024-06899-3] [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: 08/29/2023] [Revised: 12/31/2023] [Accepted: 02/01/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVE To investigate the potential risk factors for mortality in fungal infection in anti-melanoma differentiation-associated gene 5 antibody-positive associated interstitial lung disease (MDA5-ILD). METHODS Patients diagnosed with MDA5-ILD from April 2017 to November 2022 were included. The demographic data, laboratory examinations, therapeutic and follow-up information were recorded. Fungal infection diagnosis was established based on a combinations of host factors, clinical features and mycologic evidences. High-dose corticosteroid therapy was defined as the initial corticosteroid doses > 240mg/d. The primary endpoint was mortality. Potential factors for fungal infection occurrence and prognostic factors were analyzed using logistic regression analysis and Cox proportional hazards regression. RESULTS In total, 121 patients with MDA5-ILD were included. During follow-up, 41 (33.9%) patients had suffered fungal infection and 39.0% (16/41) of whom had ever received high-dose corticosteroid therapy. The median interval from corticosteroid use to the occurrence of fungal infection was 29 (10-48) days. The mean survival time of patients with fungal infection was 234.32 ± 464.76 days. The mortality in MDA5-ILD with fungal infection was 85.4% (35/41), which was significantly higher than those without (85.4% VS 56.3%, P < 0.001). High-dose corticosteroid therapy (P = 0.049) was independent risk factor for fungal infection occurrence. Decreased serum albumin level (P = 0.024) and high-dose corticosteroid therapy (P = 0.008) were both associated with increased mortality in MDA5-ILD patients with fungal infection. CONCLUSION Fungal infection is associated with an increased mortality in MDA5-ILD. The serum albumin level and corticosteroid dose should be taken into consideration when treating MDA5-ILD. Key Points • This study showed fungal infection is associated with an increased mortality in MDA5-ILD. In MDA5-ILD patients with fungal infection, the presence of decreased serum albumin level and high-dose corticosteroid therapy were identified as predictors for mortality.
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Affiliation(s)
- Wanqing Zhou
- Department of Pulmonary and Critical Care Medicine, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, No. 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Haoran Chen
- Department of Pulmonary and Critical Care Medicine, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, No. 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Tong Ji
- Department of Pulmonary and Critical Care Medicine, Nanjing Drum Tower Hospital, The Afliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Ranxun Chen
- Department of Pulmonary and Critical Care Medicine, Nanjing Drum Tower Hospital, The Afliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Qingqing Xu
- Department of Pulmonary and Critical Care Medicine, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, No. 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
- Department of Pulmonary and Critical Care Medicine, Nanjing Drum Tower Hospital, The Afliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Lulu Chen
- Department of Pulmonary and Critical Care Medicine, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, No. 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
- Department of Pulmonary and Critical Care Medicine, Nanjing Drum Tower Hospital, The Afliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Min Cao
- Department of Pulmonary and Critical Care Medicine, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, No. 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
- Department of Pulmonary and Critical Care Medicine, Nanjing Drum Tower Hospital, The Afliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Hourong Cai
- Department of Pulmonary and Critical Care Medicine, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, No. 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
- Department of Pulmonary and Critical Care Medicine, Nanjing Drum Tower Hospital, The Afliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Jinghong Dai
- Department of Pulmonary and Critical Care Medicine, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, No. 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China.
- Department of Pulmonary and Critical Care Medicine, Nanjing Drum Tower Hospital, The Afliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China.
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Ahmadpour E, Valilou S, Ghanizadegan MA, Seyfi R, Hosseini SA, Hatam-Nahavandi K, Hosseini H, Behravan M, Barac A, Morovati H. Global prevalence, mortality, and main characteristics of HIV-associated pneumocystosis: A systematic review and meta-analysis. PLoS One 2024; 19:e0297619. [PMID: 38526997 PMCID: PMC10962827 DOI: 10.1371/journal.pone.0297619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 01/09/2024] [Indexed: 03/27/2024] Open
Abstract
The epidemiology of Human Immunodeficiency Virus (HIV)-associated pneumocystosis (HAP) is poorly described on a worldwide scale. We searched related databases between January 2000 and December 2022 for studies reporting HAP. Meta-analysis was performed using StatsDirect (version 2.7.9) and STATA (version 17) according to the random-effects model for DerSimonian and Laird method and metan and metaprop commands, respectively. Twenty-nine studies with 38554 HIV-positive, 79893 HIV-negative, and 4044 HAP populations were included. The pooled prevalence of HAP was 35.4% (95% CI 23.8 to 47.9). In contrast, the pooled prevalence of PCP among HIV-negative patients was 10.16% (95% CI 2 to 25.3). HIV-positive patients are almost 12 times more susceptible to PCP than the HIV-negative population (OR: 11.710; 95% CI: 5.420 to 25.297). The mortality among HAP patients was 52% higher than non-PCP patients (OR 1.522; 95% CI 0.959 to 2.416). HIV-positive men had a 7% higher chance rate for PCP than women (OR 1.073; 95% CI 0.674 to 1.706). Prophylactic (OR: 6.191; 95% CI: 0.945 to 40.545) and antiretroviral therapy (OR 3.356; 95% CI 0.785 to 14.349) were used in HAP patients six and three times more than HIV-positive PCP-negatives, respectively. The control and management strategies should revise and updated by health policy-makers on a worldwide scale. Finally, for better management and understanding of the epidemiology and characteristics of this coinfection, designing further studies is recommended.
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Affiliation(s)
- Ehsan Ahmadpour
- Infectious and Tropical Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Medical Mycology and Parasitology, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sevda Valilou
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Rouhollah Seyfi
- Infectious and Tropical Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Seyed Abdollah Hosseini
- Department of Parasitology and Mycology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | | | - Hanieh Hosseini
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mahsa Behravan
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Aleksandra Barac
- Clinic for Infectious and Tropical Diseases, University Clinical Center of Serbia, Belgrade, Serbia
| | - Hamid Morovati
- Department of Medical Mycology and Parasitology, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Yin Y, Shen K, Li H, Zhang L. Pneumocystis jirovecii Pneumonia Secondary to Blinatumomab Therapy: A Case Report. Chemotherapy 2024; 69:104-107. [PMID: 38508148 DOI: 10.1159/000538256] [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] [Received: 12/31/2023] [Accepted: 02/29/2024] [Indexed: 03/22/2024]
Abstract
INTRODUCTION With the increasing use of blinatumomab in relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL), including minimal residual disease (MRD)-positive cases, awareness of its adverse effects has gradually improved. Pneumocystis jirovecii pneumonia (PCP) associated with blinatumomab therapy is rare. CASE PRESENTATION We present a case of PCP in a patient undergoing blinatumomab therapy. A 70-year-old female diagnosed with Philadelphia-like CRLF2 overexpression B-cell precursor ALL received blinatumomab as consolidation therapy after achieving complete remission with prior induction chemotherapy. On the second day of blinatumomab infusion, she developed intermittent low-grade fever, and chest computed tomography (CT) revealed subtle infiltrates and nodules. Despite empiric trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis, she progressed to significant shortness of breath and type I respiratory failure, with increased lactate dehydrogenase and β-D-glucan assays. Chest CT showed diffuse ground-glass opacities with scattered small nodules. The dry cough prompted next-generation sequencing of peripheral blood, which tested positive for pneumocystis jirovecii without evidence of other pathogens. Consequently, the patient was diagnosed with PCP. The first cycle of blinatumomab had to be discontinued, and therapeutic dosages of TMP-SMX and dexamethasone were administered, resulting in full recovery and stable condition during follow-ups. CONCLUSION PCP is rare in B-cell precursor ALL patients receiving blinatumomab therapy but manifests with early onset and rapid disease progression. Despite prophylaxis, PCP infection cannot be ignored during blinatumomab therapy. Therefore, heightened attention is warranted when using blinatumomab therapy.
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Affiliation(s)
- Yue Yin
- Division of General Internal Medicine, Department of Primary Care and Family Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China
| | - Kaini Shen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hanyu Li
- Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lu Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Kaneda Y, Gonda K, Asakura T, Wada M, Sawano T, Kurokawa T, Tachibana K, Ozaki A. Pneumocystis Pneumonia in Locally Advanced Breast Cancer Despite Prophylactic Use of Trimethoprim-Sulfamethoxazole During Prednisolone Treatment for a Pembrolizumab-Induced Immune-Related Adverse Event: A Case Report. Cureus 2024; 16:e56868. [PMID: 38659518 PMCID: PMC11040520 DOI: 10.7759/cureus.56868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2024] [Indexed: 04/26/2024] Open
Abstract
Pneumocystis pneumonia (PCP) primarily affects immunosuppressed patients, with trimethoprim-sulfamethoxazole (TMP-SMX) commonly used for prophylaxis. However, there is insufficient information on PCP occurrence despite TMP-SMX prophylaxis. We encountered a 57-year-old woman with locally advanced breast cancer developing PCP despite prophylactic intake of TMP-SMX, during treatment with prednisolone for Stevens-Johnson syndrome (SJS) induced by pembrolizumab. This case underscores the need to pay attention to the possibility of PCP development even during TMP-SMX prophylaxis. Dosage and duration adjustments according to the patient's condition and weight may be required.
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Affiliation(s)
- Yudai Kaneda
- School of Medicine, Hokkaido University, Sapporo, JPN
| | - Kenji Gonda
- Department of Breast Surgery, Jyoban Hospital, Iwaki, JPN
| | - Takanori Asakura
- Division of Pulmonology, Kitasato University Hospital, Tokyo, JPN
| | - Masahiro Wada
- Department of Breast Surgery, Jyoban Hospital, Iwaki, JPN
| | | | | | | | - Akihiko Ozaki
- Department of Breast Surgery, Jyoban Hospital, Iwaki, JPN
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Qian Y, Zhang Y, Huang J, Liu J, Chen G, Xia G, Wang C, Feng A, Chen Y, Chen J, Zeng Y, Nie X. Risk Factors for Pneumocystis jirovecii Pneumonia in Children With Systemic Lupus Erythematosus Exposed to Prolonged High-Dose Glucocorticoids. J Clin Rheumatol 2024:00124743-990000000-00189. [PMID: 38389131 DOI: 10.1097/rhu.0000000000002073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PJP) is a life-threatening opportunistic infection in immunocompromised children with systemic lupus erythematosus (SLE). Prophylaxis against PJP in high-risk children is crucial, but the risk factors for PJP in children with SLE are not adequately characterized. This study sought to identify the risk factors for PJP in long-term glucocorticoid-treated pediatric SLE patients. METHODS This study encompassed 71 treatment episodes involving 64 children with prolonged (≥4 weeks) high-dose (≥20 mg/d prednisone) steroid regimens. Fourteen treatment episodes involved the PJP, whereas others did not. Risk factors for PJP were assessed through Cox regression. The predictive value of these factors was evaluated using receiver operating characteristic curves. The incidence of PJP in different risk groups was compared using the Kaplan-Meier method. RESULTS The creatinine (hazard ratio, 1.009; 95% confidence interval [CI], 1.001-1.017; p = 0.021) and the lowest lymphocyte count (hazard ratio, 0.007; 95% CI, 0.000-0.373; p = 0.014) were independent risk factors for PJP in children with SLE. The receiver operating characteristic curve showed that using creatinine greater than 72.5 μmol/L and the lowest lymphocyte count less than 0.6 × 109/L as risk predictors for PJP resulted in an area under the curve value of 0.934 (95% CI, 0.870-0.997; p < 0.001). The study revealed a significant increase in PJP prevalence (p < 0.001) in children with elevated creatinine levels and low lymphocyte count. CONCLUSIONS Elevated levels of creatinine and decreased lymphocyte count are identified as distinct risk factors for PJP in children with SLE who receive prolonged high-dose steroid therapy.
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Affiliation(s)
| | | | | | - Jingjing Liu
- Department of Pediatrics, The 900th Hospital of the Joint Logistic Support Force, Fuzhou, China
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10
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Nettleton E, Sattui SE, Wallace Z, Putman M. Incidence of Pneumocystis Jiroveci Pneumonia in Patients With ANCA-Associated Vasculitis Initiating Therapy With Rituximab or Cyclophosphamide. Arthritis Care Res (Hoboken) 2024; 76:288-294. [PMID: 37643919 PMCID: PMC10841679 DOI: 10.1002/acr.25222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 07/28/2023] [Accepted: 08/24/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVE This manuscript assesses the incidence of Pneumocystis jiroveci pneumonia (PJP) among patients receiving contemporary treatment regimens for antineutrophil cytoplasmic antibody-associated vasculitis (AAV) and adverse events associated with PJP prophylaxis. METHODS Incident users of rituximab or cyclophosphamide for AAV were identified in the TriNetX electronic health records database from 2011 to 2022. The incidence rates (IRs) of PJP in the first 6 months of induction therapy with rituximab and/or cyclophosphamide and during postinduction maintenance therapy with rituximab were calculated. Cox proportional hazard models were used to estimate hazard ratios (HRs) and confidence intervals (CIs) for the risk of adverse events commonly associated with PJP prophylaxis. RESULTS We identified 1,461 AAV cases who received induction therapy with rituximab (69.7%), cyclophosphamide (18.9%), or both (11.4%). Prophylaxis prescribed within 30 days of induction included trimethoprim-sulfamethoxazole (30.7%), atovaquone (5.4%), dapsone (3.8%), and pentamidine (0.8%). During induction therapy, 10 cases of PJP were identified (IR 15.0 cases per 1,000 patient-years); no deaths occurred. In adjusted analyses, those who received prophylaxis had a higher risk of leukopenia (HR 3.1; 95% CI 1.1-8.6), rash (HR 1.9; 95% CI 1.0-3.6), and nephropathy (HR 2.6; 95% CI 1.3-5.1) than those who did not. During rituximab maintenance therapy (n = 709), five cases of PJP were identified (IR 2.1 cases per 1,000 person-years), one of whom died during the hospitalization associated with a PJP diagnosis. CONCLUSION Rates of PJP in patients with AAV were lower than previously observed, and few cases occurred during rituximab maintenance therapy. PJP prophylaxis was associated with adverse events.
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Affiliation(s)
| | - Sebastian E Sattui
- University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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11
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Stellern JJ, Plaisted J, Welles C. Disseminated nocardiosis with persistent neurological disease. BMJ Case Rep 2024; 17:e257935. [PMID: 38195189 PMCID: PMC10806866 DOI: 10.1136/bcr-2023-257935] [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: 01/11/2024] Open
Abstract
A man in his 80s with a history of sarcoidosis on chronic prednisone presented to the emergency department with several days of dyspnoea. A chest X-ray showed signs of pneumonia, and the patient was admitted. Blood and pleural fluid cultures grew Nocardia farcinica; therefore, the patient was started on treatment with trimethoprim-sulbactam and imipenem. Brain imaging showed evidence of dissemination of the infection to the central nervous system (CNS). The patient's admission was complicated by pleural effusions, acute kidney injury and pancytopenia, and therefore, his antibiotic regimen was ultimately transitioned from trimethoprim-sulfamethoxazole (TMP-SMX), meropenem and linezolid to imipenem and tedizolid. The patient received imipenem and tedizolid for the remainder of the admission. A repeat MRI of the brain was performed after 6 weeks of this dual antibiotic therapy, which unfortunately revealed persistent CNS disease. His regimen was then broadened to TMP-SMX, linezolid and imipenem. Despite these measures, however, the patient ultimately passed away from the infection.
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Affiliation(s)
| | - Jacob Plaisted
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Christine Welles
- University of Colorado School of Medicine, Aurora, Colorado, USA
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12
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Hellmich B, Sanchez-Alamo B, Schirmer JH, Berti A, Blockmans D, Cid MC, Holle JU, Hollinger N, Karadag O, Kronbichler A, Little MA, Luqmani RA, Mahr A, Merkel PA, Mohammad AJ, Monti S, Mukhtyar CB, Musial J, Price-Kuehne F, Segelmark M, Teng YKO, Terrier B, Tomasson G, Vaglio A, Vassilopoulos D, Verhoeven P, Jayne D. EULAR recommendations for the management of ANCA-associated vasculitis: 2022 update. Ann Rheum Dis 2024; 83:30-47. [PMID: 36927642 DOI: 10.1136/ard-2022-223764] [Citation(s) in RCA: 112] [Impact Index Per Article: 112.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/21/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Since the publication of the EULAR recommendations for the management of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) in 2016, several randomised clinical trials have been published that have the potential to change clinical care and support the need for an update. METHODS Using EULAR standardised operating procedures, the EULAR task force undertook a systematic literature review and sought opinion from 20 experts from 16 countries. We modified existing recommendations and created new recommendations. RESULTS Four overarching principles and 17 recommendations were formulated. We recommend biopsies and ANCA testing to assist in establishing a diagnosis of AAV. For remission induction in life-threatening or organ-threatening AAV, we recommend a combination of high-dose glucocorticoids (GCs) in combination with either rituximab or cyclophosphamide. We recommend tapering of the GC dose to a target of 5 mg prednisolone equivalent/day within 4-5 months. Avacopan may be considered as part of a strategy to reduce exposure to GC in granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA). Plasma exchange may be considered in patients with rapidly progressive glomerulonephritis. For remission maintenance of GPA/MPA, we recommend rituximab. In patients with relapsing or refractory eosinophilic GPA, we recommend the use of mepolizumab. Azathioprine and methotrexate are alternatives to biologics for remission maintenance in AAV. CONCLUSIONS In the light of recent advancements, these recommendations provide updated guidance on AAV management. As substantial data gaps still exist, informed decision-making between physicians and patients remains of key relevance.
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Affiliation(s)
- Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken, Akademisches Lehrkrankenhaus der Universität Tübingen, Kirchheim unter Teck, Germany
| | | | - Jan H Schirmer
- Rheumatology & Clinical Immunology and Cluster of Excellence Precision Medicine in Chronic Inflammation, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Alvise Berti
- CIBIO, Universita degli Studi di Trento, Trento, Italy
- Rheumatology, Santa Chiara Hospital, Trento, Italy
| | - Daniel Blockmans
- Department of Internal Medicine, University Hospital of Leuven, Leuven, Belgium
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumuenster, Germany
| | - Nicole Hollinger
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken, Akademisches Lehrkrankenhaus der Universität Tübingen, Kirchheim unter Teck, Germany
| | - Omer Karadag
- Division of Rheumatology, Department of Internal Medicine, Vasculitis Research Center, Hacettepe University School of Medicine, Anakra, Turkey
| | - Andreas Kronbichler
- Department of Internal Medicine IV, Medical University, Innsbruck, Austria
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Mark A Little
- Trinity Health Kidney Centre, Trinity College Dublin, Dublin, Ireland
| | - Raashid A Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMs), University of Oxford, Oxford, UK
| | - Alfred Mahr
- Klinik für Rheumatologie, Kantonspital St Gallen, St Gallen, Switzerland
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aladdin J Mohammad
- Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Clinical Sciences, Lund University & Department of Rheumatology, Skåne Hospital, Lund, Sweden
| | - Sara Monti
- Department of Internal Medicine and Therapeutics, Università di Pavia, Pavia, Italy
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Chetan B Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - Jacek Musial
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Kraków, Poland
| | | | - Mårten Segelmark
- Division of Nephrology, Department of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Y K Onno Teng
- Centre of Expertise for Lupus-, Vasculitis-, and Complement-Mediated Systemic Autoimmune Diseases (LuVaCs), Department of Internal Medicine, Section Nephrology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Gunnar Tomasson
- Department of Epidemiology and Biostatistics, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Rheumatology and Centre for Rheumatology Research, University Hospital Reykjavik, Reykjavik, Iceland
| | - Augusto Vaglio
- Nephrology Unit, Meyer Children's Hospital, and Department of Biomedical, Experimental and Clinical Science, University of Florence, Florence, Italy
| | - Dimitrios Vassilopoulos
- 2nd Department of Medicine and Laboratory, Clinical Immunology-Rheumatology Unit, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, Athens, Greece
| | - Peter Verhoeven
- Dutch Patient Vasculitis Organization, Haarlem, The Netherlands
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
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Quigley N, d’Amours L, Gervais P, Dion G. Epidemiology, Risk Factors, and Prophylaxis Use for Pneumocystis jirovecii Pneumonia in the Non-HIV Population: A Retrospective Study in Québec, Canada. Open Forum Infect Dis 2024; 11:ofad639. [PMID: 38274551 PMCID: PMC10810061 DOI: 10.1093/ofid/ofad639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 12/13/2023] [Indexed: 01/27/2024] Open
Abstract
Background Pneumocystis jirovecii pneumonia (PJP) remains a significant threat in immunocompromised cases. Recent data on epidemiology and risk factors for PJP in non-HIV cases are scarce, and guidelines on appropriate prophylaxis are lacking. Methods In this multicenter retrospective trial, all non-HIV adult cases admitted to hospitals in Québec City, Canada, between January 2011 and January 2021 with a diagnosis of PJP were assessed for eligibility. Results An overall 129 cases of PJP were included. More than two-thirds had an underlying hematologic disease or an autoimmune/inflammatory condition. Prior to diagnosis, 83.7% were taking corticosteroids, 71.3% immunosuppressive agents (alone or in combination with corticosteroids), and 62% both. A diagnosis of PJP was noted in 22 patients receiving corticosteroids for treatment <28 days. Two patients developed PJP while undergoing corticosteroid monotherapy at a mean daily prednisone-equivalent dose <20 mg/d; 4.7% of our cohort received a PJP prophylaxis. Current recommendations or accepted clinical practices for PJP prophylaxis would not have applied to 48.8% of our patients. Conclusions The use of corticosteroids-in monotherapy or in coadministration with other immunosuppressive agents-remains the principal risk factor for PJP in the non-HIV population. Current prophylaxis guidelines and accepted practices are insufficient to adequately prevent PJP and need to be broadened and updated.
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Affiliation(s)
- Nicholas Quigley
- Department of Pulmonary Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Québec Heart and Lung Institute), Université Laval, Québec City, Québec
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta
| | - Laurence d’Amours
- Department of Pulmonary Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Québec Heart and Lung Institute), Université Laval, Québec City, Québec
| | - Philippe Gervais
- Department of Microbiology and Infectious Diseases, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Québec Heart and Lung Institute), Université Laval, QuébecCity, Québec, Canada
| | - Geneviève Dion
- Department of Pulmonary Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Québec Heart and Lung Institute), Université Laval, Québec City, Québec
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Miyake K, Kawamura T, Nakahara Y, Sasaki S. A single-center, person-month-based analysis of the risk of developing Pneumocystis pneumonia (PCP) in immunosuppressed non-HIV patients: Preventive effects of trimethoprim-sulfamethoxazole. J Infect Chemother 2023; 29:1097-1102. [PMID: 37499901 DOI: 10.1016/j.jiac.2023.07.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 06/20/2023] [Accepted: 07/24/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVE We performed a retrospective study to evaluate the risk factors for acquiring Pneumocystis pneumonia (PCP) by pharmacologically immunosuppressed HIV-negative patients. METHODS Patients who received corticosteroids, immunosuppressive agents, anticancer agents, and radiotherapy with or without trimethoprim-sulfamethoxazole (TMP-SMX) at Himeji Medical Center between 2010 and 2021 were evaluated. Drugs and doses of the treatments for each patient were divided by month into person-month units. Each person-month datum includes information on the administered drug (or radiotherapy), average doses, and whether the patient had PCP during the corresponding month. ROC curves with person-month data were generated for each treatment, and AUCs >0.7 were identified as possessing positive classification utility. The risks for PCP according to gender, age (grouped by median) and each treatment were examined by univariate analysis, followed by multivariate analysis to identify independent factors. RESULTS Of a total of 17,733 patients (214,676 person-months), 32 developed PCP. The cut-off values by ROC analysis were 13.7 mg/day for corticosteroid (prednisolone equivalent), 0.92 mg/day (6.45 mg/week) for methotrexate (MTX), and 34.3 mg/day for TMP-SMX. The cut-off values for other treatments could not be estimated. The above three drugs and male sex were significant variables in univariate analysis and were all confirmed as independent factors by multivariate analysis. CONCLUSION The results suggest that a monthly average dose of ≥13.7 mg/day of prednisolone, ≥0.92 mg/day of MTX and male sex are significant independent risk factors for PCP, and that prophylaxis with ≥34.3 mg/day of TMP-SMX is to be recommended.
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Affiliation(s)
- Kohei Miyake
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Japan.
| | - Tetsuji Kawamura
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Japan
| | - Yasuharu Nakahara
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Japan
| | - Shin Sasaki
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Japan
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15
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Xiong A, Luo W, Tang X, Cao Y, Xiang Q, Deng R, Shuai S. Risk factors for invasive fungal infections in patients with connective tissue disease: Systematic review and meta-analysis. Semin Arthritis Rheum 2023; 63:152257. [PMID: 37633041 DOI: 10.1016/j.semarthrit.2023.152257] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 07/25/2023] [Accepted: 08/15/2023] [Indexed: 08/28/2023]
Abstract
OBJECTIVE Invasive fungal infections (IFIs) are life-threatening opportunistic infections in patients with connective tissue disease CTD) that cause significant morbidity and mortality. We attempted to determine the potential risk factors associated with IFIs in CTD. METHODS We systematically searched PubMed, Embase, and the Cochrane Library databases for relevant articles published from the database inception to February 1, 2023. RESULTS Twenty-six studies were included in this systematic review and meta-analysis. Risk factors identified for IFIs were diabetes (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.00 to 2.64), pulmonary diseases (OR 3.43; 95% CI 2.49 to 4.73), interstitial lung disease (ILD; OR, 4.06; 95% CI, 2.22 to 7.41), renal disease (OR, 4.41; 95% CI, 1.84 to 10.59), glucocorticoid (GC) use (OR, 4.15; 95% CI, 2.74 to 6.28), especially moderate to high-dose GC, azathioprine (AZA) use (OR, 1.50; 95% CI, 1.12 to 2.01), calcineurin inhibitor (CNI) use (OR, 2.49; 95% CI, 1.59 to 3.91), mycophenolate mofetil (MMF) use (OR, 2.83; 95% CI, 1.59 to 5.03), cyclophosphamide (CYC) use (OR, 3.35; 95% CI, 2.47 to 4.54), biologics use (OR, 3.43; 95% CI, 2.36 to 4.98), and lymphopenia (OR, 4.26; 95% CI, 2.08 to 8.73). Hydroxychloroquine (HCQ) use reduced risk of IFIs (OR, 0.67; 95% CI, 0.54 to 0.84). Furthermore, 17 of the 26 studies only reported risk factors for Pneumocystis jiroveci pneumonia (PJP) in patients with CTD. Pulmonary disease; ILD; and the use of GC, CNIs, CYC, methotrexate (MTX), MMF and biologics, and lymphopenia increased the risk of PJP, whereas the use of HCQ reduced its risk. CONCLUSION Diabetes, pulmonary disease, ILD, renal disease, use of GC (especially at moderate to high dose) and immunosuppressive drugs, and lymphopenia were found to be associated with significant risk for IFIs (especially PJP) in patients with CTD. Furthermore, the use of HCQ may reduce the risk of IFIs in patients with CTD.
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Affiliation(s)
- Anji Xiong
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China; Inflammation and Immunology Key Laboratory of Nanchong, Nanchong, China.
| | - Wenxuan Luo
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Xiaoyu Tang
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Yuzi Cao
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Qilang Xiang
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Ruiting Deng
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Shiquan Shuai
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan, China; Inflammation and Immunology Key Laboratory of Nanchong, Nanchong, China
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16
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Zhou S, Aitken SL. Prophylaxis Against Pneumocystis Pneumonia-Reply. JAMA 2023; 330:1909. [PMID: 37988090 DOI: 10.1001/jama.2023.18865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Affiliation(s)
- Shiwei Zhou
- Department of Internal Medicine, Michigan Medicine, Ann Arbor
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17
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Caplan AS, Mecoli CA, Micheletti RG. Prophylaxis Against Pneumocystis Pneumonia. JAMA 2023; 330:1908-1909. [PMID: 37988097 DOI: 10.1001/jama.2023.18862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Affiliation(s)
- Avrom S Caplan
- Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, New York
| | - Christopher A Mecoli
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robert G Micheletti
- Departments of Dermatology and Medicine, University of Pennsylvania, Philadelphia
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18
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Nakaya I, Sada KE, Harigai M, Soma J, Amano K, Dobashi H, Atsumi T, Yuzawa Y, Fujimoto S, Sugihara T, Takasaki Y, Arimura Y, Makino H. Chemoprophylaxis against Pneumocystis jirovecii pneumonia in Japanese patients with ANCA-associated vasculitis: An observational study. Mod Rheumatol 2023; 33:1137-1144. [PMID: 36197746 DOI: 10.1093/mr/roac124] [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] [Received: 08/22/2022] [Revised: 09/23/2022] [Accepted: 09/29/2022] [Indexed: 11/14/2022]
Abstract
OBJECTIVES This study investigated the current practice of prophylactic treatment against Pneumocystis jirovecii pneumonia (PCP) and its effectiveness in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV). METHODS This study included 319 patients registered from 53 institutions in Japan and newly diagnosed with AAV. During the 2-year observation period, we examined the frequency of usage, effectiveness and safety of prophylactic drugs against PCP. RESULTS Most patients received prophylactic drugs against PCP with the initiation of immunosuppressive agents, and >50% of them remained on chemoprophylaxis against PCP at 2 years after. The initial daily dose of oral prednisolone and the proportion of cyclophosphamide administration were higher in patients who received chemoprophylaxis against PCP than in those who did not. PCP occurred in nine patients (3%) and resulted in the death of four. The incidence rate of PCP in patients who received chemoprophylaxis was 1.13/100 patient-years (95% confidence interval, 0.38-2.68) and that in those who did not was 2.74 (1.04-6.02). The incidence rate ratio was 0.41 (0.11-1.53). CONCLUSIONS The markedly low incidence of PCP may be attributed to the continuous chemoprophylaxis against PCP received by >50% of Japanese patients with AAV, although the effectiveness of chemoprophylaxis against PCP was not statistically confirmed.
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Affiliation(s)
- Izaya Nakaya
- Department of Nephrology and Rheumatology, Iwate Prefectural Central Hospital, Morioka, Japan
| | - Ken-Ei Sada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
- Department of Clinical Epidemiology, Kochi Medical School, Kochi University, Nankoku, Japan
| | - Masayoshi Harigai
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Jun Soma
- Department of Nephrology and Rheumatology, Iwate Prefectural Central Hospital, Morioka, Japan
| | - Koichi Amano
- Department of Rheumatology and Clinical Immunology, Saitama Medical Centre, Saitama Medical University, Saitama, Japan
| | - Hiroaki Dobashi
- Division of Hematology, Rheumatology and Respiratory Medicine, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Miki, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Yukio Yuzawa
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Shouichi Fujimoto
- Department of Hemovascular Medicine and Artificial Organs, Faculty of Medicine, Miyazaki University, Miyazaki, Japan
| | - Takahiko Sugihara
- Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
- Division of Rheumatology & Allergology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yoshinari Takasaki
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yoshihiro Arimura
- Nephrology and Rheumatology, First Department of Internal Medicine, Kyorin University School of Medicine, Tokyo, Japan
- Department of Internal Medicine, Kichijoji Asahi Hospital, Tokyo, Japan
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19
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Park JW, Curtis JR, Choi SR, Kim MJ, Ha YJ, Kang EH, Lee YJ, Lee EB. Risk-Benefit Analysis of Primary Prophylaxis Against Pneumocystis Jirovecii Pneumonia in Patients With Rheumatic Diseases Receiving Rituximab. Arthritis Rheumatol 2023; 75:2036-2044. [PMID: 37096489 DOI: 10.1002/art.42541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 03/31/2023] [Accepted: 04/20/2023] [Indexed: 04/26/2023]
Abstract
OBJECTIVE To identify a specific population of patients with rheumatic diseases receiving rituximab treatment for whom the benefit from primary prophylaxis against Pneumocystis jirovecii pneumonia (PJP) outweighs the risk of adverse events (AEs). METHODS This study included 818 patients treated with rituximab for rheumatic diseases, among whom 419 received prophylactic trimethoprim/sulfamethoxazole (TMP/SMX) with rituximab, while the remainder did not. Differences in 1-year PJP incidence between the groups were estimated using Cox proportional hazards regression. Risk-benefit assessment was performed in subgroups stratified according to risk factors based on the number needed to treat (NNT) to prevent 1 case of PJP and the number needed to harm (NNH) due to severe AEs. Inverse probability of treatment weighting was applied to minimize the confounding by indication. RESULTS During the 663.1 person-years, there were 11 PJP cases, with a mortality rate of 63.6%. Concomitant use of high-dose glucocorticoids (≥30 mg/day of prednisone or equivalent during 4 weeks after rituximab administration) was the most important risk factor. The PJP incidence (per 100 person-years) was 7.93 (95% confidence interval [95% CI] 2.91-17.25) in the subgroup receiving high-dose glucocorticoids compared with 0.40 (95% CI 0.01-2.25) in the subgroup without high-dose glucocorticoid use. Although prophylactic TMP/SMX significantly reduced the overall PJP incidence (HR 0.11 [95% CI 0.03-0.43]), the NNT to prevent 1 case of PJP (146) was higher than the NNH (86). In contrast, the NNT fell to 20 (95% CI 10.7-65.7) in patients receiving concomitant high-dose glucocorticoids. CONCLUSION The benefit associated with primary PJP prophylaxis outweighs the risk of severe AEs in patients with rheumatic diseases receiving rituximab and concomitant high-dose glucocorticoid treatment.
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Affiliation(s)
- Jun Won Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeffrey R Curtis
- Division of Clinical Immunology & Rheumatology, University of Alabama at Birmingham
| | - Se Rim Choi
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Min Jung Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University, Boramae Medical Center, Seoul, Republic of Korea
| | - You-Jung Ha
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Eun Ha Kang
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Yun Jong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, and Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Eun Bong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, and Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Republic of Korea
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20
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Cáceres Medina JL, Gamboa Meza A, Hernández Padilla IE. Two types of abdominal pain as the initial presentation of Takayasu arteritis: A case report. Int J Rheum Dis 2023; 26:2076-2079. [PMID: 37098726 DOI: 10.1111/1756-185x.14709] [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] [Received: 12/28/2022] [Revised: 02/09/2023] [Accepted: 04/10/2023] [Indexed: 04/27/2023]
Abstract
BACKGROUND Takayasu arteritis (TA) is a chronic inflammatory arteritis affecting large vessels, predominantly the aorta and its main branches. Diagnosis is usually delayed in most patients owing to the absence of typical clinical manifestations in the acute phase until the development of substantial arterial symptoms. The purpose of this case report is to describe abdominal pain being an uncommon symptom in TA. LEARNING OBJECTIVE The clinical presentation of TA can be non-specific and can have serious consequences if the diagnosis is delayed, helping the clinicians who can treat with such patients (emergency medicine, cardiologist, or medical personnel).
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Affiliation(s)
- José Luis Cáceres Medina
- Internal Medicine Department, University Hospital "Dr. José Eleuterio González", Monterrey, Nuevo León, Mexico
| | - Alan Gamboa Meza
- Internal Medicine Department, University Hospital "Dr. José Eleuterio González", Monterrey, Nuevo León, Mexico
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21
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Liu L, Zhang Y, Liu S, Wang C, Zhang L, Guan W, Zhang X, Li W, Shu X, Li T. Compounded sulfamethoxazole improved the prognosis of dermatomyositis patients positive with anti-melanoma differentiation-associated gene 5. Rheumatology (Oxford) 2023; 62:3095-3100. [PMID: 36702462 DOI: 10.1093/rheumatology/kead034] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/03/2023] [Accepted: 01/10/2023] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES Mortality of dermatomyositis patients positive with anti-melanoma differentiation-related gene 5 antibody (anti-MDA5-DM) is alarming, especially during the first several months. Infection is an important cause of early death. As there are no reports regarding the effect of prophylactic use of compounded sulfamethoxazole (coSMZ; each tablet contains 400 mg of sulfamethoxazole and 80 mg of trimethoprim) in anti-MDA5-DM patients, we conducted this study to evaluate the efficacy of coSMZ in reducing the incidence of Pneumocystis jirovecii pneumonia (PJP). METHODS Consecutive patients with new-onset anti-MDA5-DM from June 2018 to October 2021 in our centre were retrospectively reviewed for >12 months. They were divided into two groups-coSMZ and non-coSMZ-based on the initial use of prophylactic coSMZ. Mortality and the incidence of severe infection within 12 months were compared between two groups. RESULTS Compared with the non-coSMZ group (n = 93), the coSMZ group (n = 121) had lower mortality (18.8% vs 51.1%; P < 0.001) and a lower incidence of PJP (6.8% vs 15.2%; P = 0.040) and fatal infection (16.1% vs 3.3%; P = 0.001) during the first 12 months from diagnosis. After adjusting for age, gender, disease duration, peripheral blood lymphocyte count, anti-MDA5 antibody titres, ground-glass opacity scores and treatments, an inverse association was revealed between the prophylactic use of coSMZ and incidence of PJP [adjusted odds ratio 0.299 (95% CI 0.102-0.878), P = 0.028]. CONCLUSION Prophylactic use of coSMZ is an effective and safe way to improve the prognosis of anti-MDA5-DM patients by preventing the incidence of PJP.
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Affiliation(s)
- Lijun Liu
- Department of Rheumatology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yinli Zhang
- Department of Rheumatology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shengyun Liu
- Department of Rheumatology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Cong Wang
- Department of Gynecology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lei Zhang
- Department of Rheumatology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wenjuan Guan
- Department of Rheumatology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xin Zhang
- Department of Rheumatology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wei Li
- Department of Rheumatology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaoming Shu
- Department of Rheumatology, Key Laboratory of Myositis, China-Japan Friendship Hospital, Beijing, China
| | - Tianfang Li
- Department of Rheumatology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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22
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Clemente Garulo D, Núñez-Cuadros E, Camacho Lovillo M, Calzada-Hernández J, Guillén Martín S, Fernández Silveira L, Lirola Cruz MJ, Tagarro A, Alcobendas Rueda RM, López López A, Satrustegi Aritziturri M, Calvo C. Position statement on infection screening, prophylaxis, and vaccination in pediatric patients with rheumatic diseases and immunosuppressive therapies, part 2: infection prophylaxis. Eur J Pediatr 2023; 182:4271-4284. [PMID: 37439850 PMCID: PMC10570166 DOI: 10.1007/s00431-023-05080-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 06/18/2023] [Accepted: 06/21/2023] [Indexed: 07/14/2023]
Abstract
This study aims to provide practical recommendations on prophylaxis for infection in pediatric patients with immune-mediated rheumatic diseases receiving/scheduled to receive immunosuppressive therapy. A qualitative approach was applied. A narrative literature review was performed via Medline. Primary searches were conducted using MeSH terms and free text to identify articles that analyzed data on infections and vaccinations in pediatric patients with immune-mediated rheumatic diseases receiving immunosuppressive therapy. The results were presented and discussed in a nominal group meeting comprising a committee of 12 pediatric rheumatologists from the Prevention and Treatment of Infections Working Group of the Spanish Society of Pediatric Rheumatology. Several recommendations were generated. A consensus procedure was implemented via a Delphi process that was extended to members of the Spanish Society of Pediatric Rheumatology and the Vaccine Advisory Committee of the Spanish Association of Pediatrics. Participants produced a score ranging from 0 (completely disagree) to 10 (completely agree). Agreement was considered to have been reached if at least 70% of participants voted ≥ 7. The literature review included more than 400 articles. Overall, 63 recommendations were generated (23 on infection prophylaxis) and voted by 59 pediatric rheumatologists and other pediatric specialists, all of whom achieved the pre-established level of agreement. The recommendations on prophylaxis of infection cover vaccination and prophylaxis against varicella zoster virus, tuberculosis, Pneumocystis jiroveccii, and invasive fungal infections in pediatric patients with immune-mediated rheumatic diseases receiving/scheduled to receive immunosuppressive therapy. Conclusion: Based on current evidence and a Delphi process, we provided consensus and updated recommendations on prophylaxis and treatment of infections to guide those caring for pediatric rheumatology patients. What is Known: •Data largely derived from adults find that infectious diseases and related complications are a major cause of morbidity and mortality in patients with immune-mediated rheumatic diseases. •It is crucial to be aware of the preventive measures that should be implemented to prevent these infections in children, although most guidelines are often extrapolated from adult cases. What is New: •In the absence of evidence, a literature review and a Delphi survey were conducted to establish a series of expert recommendations that could prove useful in clinical practice, providing a practical and simple day-to-day approach to be used by pediatric rheumatologists. •The recommendations focus on tuberculosis, herpes zoster virus, fungal infections, and Pneumocystis jirovecii.
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Affiliation(s)
| | - Esmeralda Núñez-Cuadros
- Pediatric Rheumatology Unit, UGC Pediatría, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Av. del Arroyo de los Ángeles, S/N, 29011, Málaga, Spain.
| | - Marisol Camacho Lovillo
- Servicio de Inmunología, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBIS), Reumatología E Infectología Pediátricas, Seville, Spain
| | - Joan Calzada-Hernández
- Unitat de Reumatologia Pediàtrica, Servei de Pediatria, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
| | - Sara Guillén Martín
- Department of Paediatrics, Hospital Universitario de Getafe, Getafe, Madrid, Spain
| | - Laura Fernández Silveira
- Servicio de Inmunología, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBIS), Reumatología E Infectología Pediátricas, Seville, Spain
| | - María José Lirola Cruz
- Department of Paediatric Rheumatology, Instituto Hispalense de Pediatría, Seville, Spain
| | - Alfredo Tagarro
- Pediatrics Department, Instituto de Investigación 12 de Octubre (imas12), Hospital Universitario Infanta Sofía, Universidad Europea, Hospital 12 de Octubre, Madrid, Spain
| | | | - Agustín López López
- Department of Paediatrics, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | | - Cristina Calvo
- Department of Pediatrics, Infectious and Tropical Diseases, Hospital Universitario La Paz, and La Paz Research Institute (IdiPaz), Madrid, Spain
- Translational Research Network of Pediatric Infectious Diseases (RITIP). Madrid, Madrid, Spain
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23
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Odler B, Windpessl M, Eller K, Säemann MD, Lhotta K, Neumann I, Öberseder G, Duftner C, Dejaco C, Rudnicki M, Gauckler P, Hintenberger R, Zwerina J, Thiel J, Kronbichler A. [Diagnosis and therapy of granulomatosis with polyangiitis and microscopic polyangiitis-2023: consensus of the Austrian society of nephrology (ÖGN) and Austrian society of rheumatology (ÖGR)]. Wien Klin Wochenschr 2023; 135:656-674. [PMID: 37728651 PMCID: PMC10511611 DOI: 10.1007/s00508-023-02262-9] [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] [Accepted: 07/24/2023] [Indexed: 09/21/2023]
Abstract
ANCA-associated vasculitides (AAV) are rare, complex systemic diseases that are often difficult to diagnose, because of unspecific clinical symptoms at presentation. However, the clinical course may be very dramatic and even life-threatening, necessitating prompt diagnosis and treatment.Therefore, it is important to increase disease awareness among physicians and support colleagues who are not confronted with these rare diseases on a regular basis. Here, the Austrian Society of Nephrology (ÖGN) and the Austrian Society of Rheumatology (ÖGR) provide a joint consensus on how to best diagnose and manage patients with granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA).
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Affiliation(s)
- Balazs Odler
- Klinische Abteilung für Nephrologie, Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Medizinische Universität Graz, Graz, Österreich
| | - Martin Windpessl
- Abteilung für Innere Medizin IV, Klinikum Wels-Grieskirchen, Wels, Österreich
- Medizinische Fakultät, JKU, Linz, Österreich
| | - Kathrin Eller
- Klinische Abteilung für Nephrologie, Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Medizinische Universität Graz, Graz, Österreich
| | - Marcus D Säemann
- 6. Medizinische Abteilung mit Nephrologie & Dialyse, Klinik Ottakring, Wien, Österreich
- Medizinische Fakultät, SFU, Wien, Österreich
| | - Karl Lhotta
- Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Akademisches Lehrkrankenhaus Feldkirch, Feldkirch, Österreich
| | - Irmgard Neumann
- Vasculitis.at, Wien, Österreich
- Immunologiezentrum Zürich (IZZ), Zürich, Schweiz
| | | | - Christina Duftner
- Department Innere Medizin II, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | | | - Michael Rudnicki
- Department Innere Medizin IV (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Philipp Gauckler
- Department Innere Medizin IV (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Rainer Hintenberger
- Abteilung Innere Medizin 2 (Gastroenterologie und Hepatologie, Endokrinologie und Stoffwechsel, Nephrologie, Rheumatologie), JKU, Linz, Österreich
| | - Jochen Zwerina
- 1. Medizinische Abteilung, Hanusch Krankenhaus, Wien, Österreich
| | - Jens Thiel
- Klinische Abteilung für Rheumatologie und Immunologie, Bereich Innere Medizin, Medizinische Universität Graz, Graz, Österreich
| | - Andreas Kronbichler
- Department Innere Medizin IV (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich.
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24
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Beck LH, Ayoub I, Caster D, Choi MJ, Cobb J, Geetha D, Rheault MN, Wadhwani S, Yau T, Whittier WL. KDOQI US Commentary on the 2021 KDIGO Clinical Practice Guideline for the Management of Glomerular Diseases. Am J Kidney Dis 2023; 82:121-175. [PMID: 37341661 DOI: 10.1053/j.ajkd.2023.02.003] [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] [Received: 12/21/2022] [Accepted: 02/20/2023] [Indexed: 06/22/2023]
Abstract
The KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases represents the first update to this set of recommendations since the initial set of KDIGO guideline recommendations was published in 2012. The pace of growth in our molecular understanding of glomerular disease has quickened and a number of newer immunosuppressive and targeted therapies have been introduced since the original set of guideline recommendations, making such an update necessary. Despite these updates, many areas of controversy remain. In addition, further updates since the publication of KDIGO 2021 have occurred which this guideline does not encompass. With this commentary, the KDOQI work group has generated a chapter-by-chapter companion opinion article that provides commentary specific to the implementation of the KDIGO 2021 guideline in the United States.
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Affiliation(s)
- Laurence H Beck
- Division of Nephrology, Department of Medicine, Chobanian & Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Isabelle Ayoub
- Department of Medicine, Division of Nephrology, Wexner Medical, The Ohio State University, Columbus, Ohio
| | - Dawn Caster
- Department of Medicine, School of Medicine, University of Louisville, Louisville, Kentucky
| | | | - Jason Cobb
- Division of Renal Medicine, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia
| | - Duvuru Geetha
- Division of Nephrology, Johns Hopkins University, Baltimore, Maryland
| | - Michelle N Rheault
- Department of Pediatrics, Division of Pediatric Nephrology, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Shikha Wadhwani
- Division of Nephrology and Hypertension, Northwestern University, Chicago, Illinois
| | - Timothy Yau
- Division of Nephrology, Department of Medicine, School of Medicine, Washington University, St. Louis, Missouri
| | - William L Whittier
- Division of Nephrology, Rush University Medical Center, Chicago, Illinois
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25
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Windpessl M, Gauckler P, Zitt E, Lhotta K, Ay C, Eller K, Odler B, Neumann I, Rudnicki M, Kronbichler A, Säemann MD. [General recommendations for the management of glomerular diseases-2023]. Wien Klin Wochenschr 2023; 135:696-704. [PMID: 37728654 PMCID: PMC10511582 DOI: 10.1007/s00508-023-02265-6] [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] [Accepted: 07/24/2023] [Indexed: 09/21/2023]
Abstract
Glomerular diseases are associated with extrarenal complications, such as thromboembolism, cardiovascular events and particularly infections. A thorough knowledge of the various immunosuppressants and their associated toxicity profile is therefore of great importance. While nephrologists usually have extensive experience with calcineurin inhibitors and antimetabolites, two other compounds (rituximab, in severe cases cyclophosphamide) are used comparatively infrequently and will be discussed in more detail. Moreover, practical recommendations for the prevention of thromboembolism in states of nephrosis and for the prophylaxis of Pneumcystic jirovecii pneumonia are provided.
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Affiliation(s)
- Martin Windpessl
- Medizinische Fakultät, JKU, Linz, Österreich
- Abteilung für Innere Medizin IV, Klinikum Wels-Grieskirchen, Wels, Österreich
| | - Philipp Gauckler
- Department Innere Medizin IV (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Emanuel Zitt
- Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Akademisches Lehrkrankenhaus Feldkirch, Feldkirch, Österreich
| | - Karl Lhotta
- Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Akademisches Lehrkrankenhaus Feldkirch, Feldkirch, Österreich
| | - Cihan Ay
- Klinische Abteilung für Hämatologie und Hämostaseologie, Universitätsklinik für Innere Medizin I, Medizinische Universität Wien, Wien, Österreich
| | - Kathrin Eller
- Klinische Abteilung für Nephrologie, Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Medizinische Universität Graz, Graz, Österreich
| | - Balazs Odler
- Klinische Abteilung für Nephrologie, Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Medizinische Universität Graz, Graz, Österreich
| | - Irmgard Neumann
- Vasculitis.at, Wien, Österreich
- Immunologiezentrum Zürich (IZZ), Zürich, Schweiz
| | - Michael Rudnicki
- Department Innere Medizin IV (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Andreas Kronbichler
- Department Innere Medizin IV (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich.
| | - Marcus D Säemann
- 6. Medizinische Abteilung mit Nephrologie & Dialyse, Klinik Ottakring, Wien, Österreich
- Medizinische Fakultät, SFU, Wien, Österreich
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26
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Mendel A, Behlouli H, de Moura CS, Vinet É, Curtis JR, Bernatsky S. Trimethoprim-sulfamethoxazole prophylaxis during treatment of granulomatosis with polyangiitis with rituximab in the United States of America: a retrospective cohort study. Arthritis Res Ther 2023; 25:133. [PMID: 37516897 PMCID: PMC10386686 DOI: 10.1186/s13075-023-03114-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/12/2023] [Indexed: 07/31/2023] Open
Abstract
BACKGROUND Antibiotic prophylaxis is recommended during ANCA-associated vasculitis (AAV) induction. We aimed to describe the frequency, persistence, and factors associated with trimethoprim-sulfamethoxazole (TMP-SMX) use in an adult population sample with granulomatosis with polyangiitis (GPA) treated with rituximab (RTX). METHODS We identified adults with GPA treated with RTX within the Merative™ Marketscan® Research Databases (2011-2020). TMP-SMX prophylaxis was defined as a [Formula: see text] 28-day prescription dispensed within a month of starting RTX. We estimated TMP-SMX persistence, allowing prescription refill gaps of 30 days. Multivariable logistic regression and Cox proportional hazards regression assessed the factors associated with baseline TMP-SMX use and persistence, respectively. Covariates included age, sex, calendar year, insurance type, immunosuppressant use, hospitalization, and co-morbidities. RESULTS Among 1877 RTX-treated GPA patients, the mean age was 50.9, and 54% were female. A minority (n = 426, 23%) received TMP-SMX with a median persistence of 141 (IQR 83-248) days. In multivariable analyses, prophylaxis was associated with prednisone use in the month prior to RTX ([Formula: see text] 20 mg/day vs none, OR 3.96; 95% CI 3.0-5.2; 1-19 mg/day vs none, OR 2.63; 95% CI 1.8-3.8), and methotrexate use (OR 1.48, 95% CI 1.04-2.1), intensive care (OR 1.95; 95% CI 1.4-2.7), and non-intensive care hospitalization (OR 1.56; 95% CI 1.2-2.1) in the 6 months prior to RTX. Female sex (OR 0.63; 95% CI 0.5-0.8) was negatively associated with TMP-SMX use. CONCLUSIONS TMP-SMX was dispensed to a minority of RTX-treated GPA patients, more often to those on glucocorticoids and with recent hospitalization. Further research is needed to determine the optimal use and duration of TMP-SMX prophylaxis following RTX in AAV.
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Affiliation(s)
- Arielle Mendel
- Division of Rheumatology, McGill University Health Centre, 1560 Cedar Avenue, Montreal, QC, H3G 1A4, Canada.
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, 5252 de Maisonneuve Blvd. W., Montreal, QC, H4A 3S9, Canada.
| | - Hassan Behlouli
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, 5252 de Maisonneuve Blvd. W., Montreal, QC, H4A 3S9, Canada
| | - Cristiano Soares de Moura
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, 5252 de Maisonneuve Blvd. W., Montreal, QC, H4A 3S9, Canada
| | - Évelyne Vinet
- Division of Rheumatology, McGill University Health Centre, 1560 Cedar Avenue, Montreal, QC, H3G 1A4, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, 5252 de Maisonneuve Blvd. W., Montreal, QC, H4A 3S9, Canada
| | - Jeffrey R Curtis
- Division of Clinical Immunology & Rheumatology, University of Alabama at Birmingham, 2000 6th Avenue South, Birmingham, AL, 35255, USA
| | - Sasha Bernatsky
- Division of Rheumatology, McGill University Health Centre, 1560 Cedar Avenue, Montreal, QC, H3G 1A4, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, 5252 de Maisonneuve Blvd. W., Montreal, QC, H4A 3S9, Canada
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27
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Guo HJ, Ye YL, Cao R, Liu ZH, He Q. Association between the cumulative dose of glucocorticoids before the development of pneumonia and death in patients receiving long-term glucocorticoids: a secondary analysis based on a Chinese cohort study. Front Med (Lausanne) 2023; 10:1175855. [PMID: 37547616 PMCID: PMC10399627 DOI: 10.3389/fmed.2023.1175855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/04/2023] [Indexed: 08/08/2023] Open
Abstract
Background The present study aimed to evaluate the association between the cumulative dose of glucocorticoids (GCs) and case fatality in hospitalized patients who developed pneumonia while receiving glucocorticoid therapy. Methods This retrospective cohort study included 625 patients receiving long-term GC treatment who were hospitalized with pneumonia (322 male and 303 female). Data were obtained from the Dryad Digital Repository and were used to perform secondary analysis. Multivariable Cox proportional hazard regression model and restricted cubic splines (RCS) were used to evaluate the association between the cumulative dose of GCs and case fatality. Sensitivity analyses and subgroup analyses were performed. Results The 30-day and 90-day death rates were 22.9 and 26.2%, respectively. After adjusting for potential confounders, compared with those in the lowest quintile (≤ 1.5 g), the Cox proportional hazard regression model analysis showed that patients with different cumulative doses of GCs (1.5 to 2.95, 2.95 to 5, 5 to 11.5, and > 11.5 g) had lower risks for 30-day death, with respective hazard ratios of 0.86 (95% CI, 0.52 to 1.42), 0.81 (0.49 to 1.33), 0.29 (0.15 to 0.55), and 0.42 (0.22 to 0.79). The multivariable-adjusted RCS analysis suggested a statistically significant N-shaped association between the cumulative dose of GCs and 30-day death. A higher cumulative dose of GC tended to first lead to an increase in 30-day death within 1.8 g, then to a statistically significant decrease until around 8 g [HR for 1 g = 0.82 (0.69 to 0.97)], and again to an increase afterward. Similar results were found in the subgroup analyses and sensitivity analyses. Conclusion N-shaped association between the cumulative dose of GCs and case fatality was observed in patients receiving long-term GC treatment who were hospitalized with pneumonia. Our findings may help physicians manage these patients.
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Affiliation(s)
- Hui-Jie Guo
- Guangdong Provincial Institute of Public Health, Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China
| | - Yi-Lu Ye
- Department of Rehabilitation Medicine, Key Laboratory of Biological Targeting Diagnosis, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Rong Cao
- Guangdong Provincial Institute of Public Health, Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China
| | - Zhi-Hua Liu
- State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qun He
- Guangdong Provincial Institute of Public Health, Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China
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28
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Qiu T, Li Y, Gong X, Zhou J, Yang K, Zhang X, Zhang Z, Lan Y, Hu F, Peng Q, Zhang Y, Kong F, Chen S, Ji Y. Oral antibiotic prophylaxis for infection in patients with vascular anomalies receiving sirolimus treatment: a multicenter retrospective study. Orphanet J Rare Dis 2023; 18:121. [PMID: 37221564 DOI: 10.1186/s13023-023-02740-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 05/18/2023] [Indexed: 05/25/2023] Open
Abstract
OBJECTIVES Patients with vascular anomalies (VAs) who receive oral sirolimus may be at high risk of infectious complications. Antibiotic prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMZ) has been advocated. However, there have been few evidence-based analyses on this topic. This study assessed the effect of prophylactic TMP-SMZ on the incidence of infections in VA patients receiving sirolimus monotherapy. METHODS A retrospective, multicenter chart review was performed on all VA patients receiving sirolimus treatment from August, 2013 to January, 2021. RESULTS Before January 2017, 112 patients were treated with sirolimus without antibiotic prophylaxis. In the subsequent period, 195 patients were treated with TMP-SMZ for at least 12 months during sirolimus therapy. The percentage of patients with at least one serious infection during the initial 12 months of sirolimus treatment did not differ between the groups (difference, 1.1%; 95% CI - 7.0-8.0%). We observed no difference in the incidence of individual infection or total adverse events between the groups. The rate of sirolimus discontinuation due to adverse events did not differ significantly between groups. CONCLUSIONS We demonstrated that prophylactic TMP-SMZ does not decrease the incidence of infection or improve tolerance in VA patients receiving sirolimus monotherapy.
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Affiliation(s)
- Tong Qiu
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
- Med-X Center for Informatics, Sichuan University, Chengdu, 610041, China
| | - Yanan Li
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
- Med-X Center for Informatics, Sichuan University, Chengdu, 610041, China
| | - Xue Gong
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Jiangyuan Zhou
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Kaiying Yang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Xuepeng Zhang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Zixin Zhang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Yuru Lan
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Fan Hu
- Department of Vascular and Interventional Radiology, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
| | - Qiang Peng
- Department of Pediatric Surgery, Chengdu Women and Children's Central Hospital, Chengdu, 610031, China
| | - Yongbo Zhang
- Department of Pediatric Surgery, Chengdu Women and Children's Central Hospital, Chengdu, 610031, China
| | - Feiteng Kong
- Department of Pediatric Surgery, Sichuan Provincial Maternity and Child Health Care Hospital, Chengdu, 610045, China
| | - Siyuan Chen
- Pediatric Intensive Care Unit, Department of Critical Care Medicine, West China Hospital of Sichuan University, 37# Guo-Xue-Xiang, Chengdu, 610041, China.
| | - Yi Ji
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China.
- Med-X Center for Informatics, Sichuan University, Chengdu, 610041, China.
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29
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Gleeson PJ, Sokol H, Monteiro RC. CARD9, VAV3, and infection risk in IgA nephropathy. Kidney Int 2023; 103:996-997. [PMID: 37085264 DOI: 10.1016/j.kint.2023.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 02/14/2023] [Indexed: 04/23/2023]
Affiliation(s)
- Patrick J Gleeson
- Paris Cité University, INSERM U1149 & CNRS EMR8252, Centre for Inflammation Research, Inflamex Laboratory of Excellenece, Paris, France; Department of Nephrology, Cork University Hospital, Cork, Ireland.
| | - Harry Sokol
- Gastroenterology Department, Sorbonne University, INSERM, Saint-Antoine Research Centre, CRSA, AP-HP, Saint-Antoine Hospital, Paris, France
| | - Renato C Monteiro
- Paris Cité University, INSERM U1149 & CNRS EMR8252, Centre for Inflammation Research, Inflamex Laboratory of Excellenece, Paris, France
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30
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Hänsel L, Schumacher J, Denis B, Hamane S, Cornely OA, Koehler P. How to diagnose and treat a non-HIV patient with Pneumocystis jirovecii pneumonia (PCP)? Clin Microbiol Infect 2023:S1198-743X(23)00186-6. [PMID: 37086781 DOI: 10.1016/j.cmi.2023.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Pneumocystis jirovecii Pneumonia (PCP) incidence is increasing in non-HIV infected patients. In contrast to PCP in patients infected with HIV, diagnosis is often delayed, and illness is associated with an increased mortality. OBJECTIVE To provide a comprehensive review of clinical presentation, risk factors, diagnostic strategies, and treatment options of PCP in non-HIV-infected patients. SOURCES Web-based literature review on PCP for trials, meta-analyses and systematic reviews using PubMed. Restriction to English language was applied. CONTENT Common underlying conditions in non-HIV-infected patients with PCP are haematological malignancies, autoimmune and inflammatory diseases, solid organ or haematopoietic stem cell transplant and prior exposure to corticosteroids. New risk groups include patients receiving monoclonal antibodies and immunomodulating therapies. Non-HIV-infected patients with PCP present with rapid onset and progression of pneumonia, increased duration of hospitalization and a significantly higher mortality rate than patients infected with HIV. PCP is diagnosed by a combination of clinical symptoms, radiological and mycological features. Immunofluorescence microscopy from bronchoalveolar lavage (BAL) or PCR testing CT imaging and evaluation of the clinical presentation are required. The established treatment regime consists of trimethoprim and sulfamethoxazole. IMPLICATIONS While the number of patients immunosuppressed for other causes than HIV is increasing, a simultaneous rise in PCP incidence is observed. In the group of non-HIV-infected patients, a rapid onset of symptoms, a more complex course, and a higher mortality rate are recorded. Therefore, time to diagnosis must be as short as possible to initiate effective therapy promptly. This review aims to raise awareness of PCP in an increasingly affected at-risk group and provide clinicians with a practical guide for efficient diagnosis and targeted therapy. Furthermore, it intends to display current inadequacies in research on the topic of PCP.
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Affiliation(s)
- Luise Hänsel
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany
| | - Jana Schumacher
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany
| | - Blandine Denis
- Department of infectious diseases, Saint Louis and Lariboisière Hospitals, APHP, Paris, France, Excellence Centre for Medical Mycology (ECMM), Paris, France
| | - Samia Hamane
- Department of infectious diseases, Saint Louis and Lariboisière Hospitals, APHP, Paris, France, Excellence Centre for Medical Mycology (ECMM), Paris, France
| | - Oliver A Cornely
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinical Trials Centre Cologne (ZKS Köln), Cologne, Germany
| | - Philipp Koehler
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany.
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Jeong HW, Lee JS, Ko JH, Hong S, Oh ST, Choi S, Peck KR, Yang JH, Chung S, Kim SH, Kim YS, Shin EC. Corticosteroids reduce pathologic interferon responses by downregulating STAT1 in patients with high-risk COVID-19. Exp Mol Med 2023; 55:653-664. [PMID: 36941461 PMCID: PMC10026241 DOI: 10.1038/s12276-023-00964-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 12/25/2022] [Accepted: 01/01/2023] [Indexed: 03/23/2023] Open
Abstract
We do not yet understand exactly how corticosteroids attenuate hyperinflammatory responses and alleviate high-risk coronavirus disease 2019 (COVID-19). We aimed to reveal the molecular mechanisms of hyperinflammation in COVID-19 and the anti-inflammatory effects of corticosteroids in patients with high-risk COVID-19. We performed single-cell RNA sequencing of peripheral blood mononuclear cells (PBMCs) from three independent COVID-19 cohorts: cohort 1 was used for comparative analysis of high-risk and low-risk COVID-19 (47 PBMC samples from 28 patients), cohort 2 for longitudinal analysis during COVID-19 (57 PBMC samples from 15 patients), and cohort 3 for investigating the effects of corticosteroid treatment in patients with high-risk COVID-19 (55 PBMC samples from 13 patients). PBMC samples from healthy donors (12 PBMC samples from 12 donors) were also included. Cohort 1 revealed a significant increase in the proportion of monocytes expressing the long noncoding RNAs NEAT1 and MALAT1 in high-risk patients. Cohort 2 showed that genes encoding inflammatory chemokines and their receptors were upregulated during aggravation, whereas genes related to angiogenesis were upregulated during improvement. Cohort 3 demonstrated downregulation of interferon-stimulated genes (ISGs), including STAT1, in monocytes after corticosteroid treatment. In particular, unphosphorylated STAT-dependent ISGs enriched in monocytes from lupus patients were selectively downregulated by corticosteroid treatment in patients with high-risk COVID-19. Corticosteroid treatment suppresses pathologic interferon responses in monocytes by downregulating STAT1 in patients with high-risk COVID-19. Our study provides insights into the mechanisms underlying COVID-19 aggravation and improvement and the effects of corticosteroid treatment.
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Affiliation(s)
- Hyun-Woo Jeong
- Department of Tissue Morphogenesis, Max Planck Institute for Molecular Biomedicine, Münster, 48149, Germany
| | - Jeong Seok Lee
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, 34141, Republic of Korea
| | - Jae-Hoon Ko
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Republic of Korea
| | - Seunghee Hong
- Department of Biochemistry, College of Life Science and Biotechnology, Yonsei University, Seoul, 03722, Korea
| | - Sang Taek Oh
- School of Mechanical Engineering, Korea University, Seoul, 02841, Republic of Korea
| | - Seongkyun Choi
- School of Mechanical Engineering, Korea University, Seoul, 02841, Republic of Korea
| | - Kyong Ran Peck
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Republic of Korea.
| | - Ji Hun Yang
- School of Mechanical Engineering, Korea University, Seoul, 02841, Republic of Korea.
| | - Seok Chung
- School of Mechanical Engineering, Korea University, Seoul, 02841, Republic of Korea.
- KU-KIST Graduate School of Converging Science and Technology, Korea University, Seoul, 02841, Republic of Korea.
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, Republic of Korea.
| | - Yeon-Sook Kim
- Division of Infectious Diseases, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, 35015, Republic of Korea.
| | - Eui-Cheol Shin
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, 34141, Republic of Korea.
- The Center for Viral Immunology, Korea Virus Research Institute, Institute for Basic Science (IBS), Daejeon, 34126, Republic of Korea.
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Clinical characteristics and risk factor analysis of Pneumocystis jirovecii pneumonia in patients with CKD: a machine learning-based approach. Eur J Clin Microbiol Infect Dis 2023; 42:323-338. [PMID: 36723755 DOI: 10.1007/s10096-023-04555-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/19/2023] [Indexed: 02/02/2023]
Abstract
Patients with chronic kidney disease (CKD) who are being treated with immunosuppressive medications are at risk for developing Pneumocystis jirovecii pneumonia (PCP). We attempted to characterize the clinical aspects of PCP in CKD patients in order to alert high-risk patients with bad prognosis. A retrospective study of CKD patients was conducted from June 2018 to June 2022. Based on PCP diagnostic criteria, these patients were divided into PCP and non-PCP groups. Using univariate and multivariate logistic regression analysis, risk indicators were evaluated, and nomogram and decision tree were developed. Of the CKD patients screened for Pneumocystis carinii nucleic acid, 1512 were included. Two-hundred forty four (16.14%) were diagnosed with PCP. Of the PCP, 88.5% was receiving glucocorticoid (GC) therapy, of which 66.3% received more than 0.5 mg/kg GC. Multivariate analysis showed that membranous nephropathy (OR 2.35, 95% CI 1.45-3.80), immunosuppressive therapy (OR 1.94, 95% CI 1.06-3.69), and ground glass opacity of CT scanning (OR 1.71, 95% CI 1.10-2.65) were associated with increased risk of Pneumocystis carinii infection. The AUC of nomogram based on logistics regression was 0.78 (0.75-0.81). The mortality in patients with PCP was 32.40%. Univariate analysis and decision tree showed that pulmonary insufficiency (PO2: OR 0.98, 95% CI 0.96-1.00), elevated APTT (OR 1.07, 95% CI 1.04-1.11), and reduced hemoglobin (OR 0.97, 95% CI 0.96-0.98) were associated with poor prognosis. PCP is not rare in CKD patients, particularly in those treated with immunosuppressive therapy. Considering the high mortality of the cases, further studies on the prevention and management of these patients are needed.
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Lang Q, Li L, Zhang Y, He X, Liu Y, Liu Z, Yan H. Development and Validation of a Diagnostic Nomogram for Pneumocystis jirovecii Pneumonia in Non-HIV-Infected Pneumonia Patients Undergoing Oral Glucocorticoid Treatment. Infect Drug Resist 2023; 16:755-767. [PMID: 36760781 PMCID: PMC9907006 DOI: 10.2147/idr.s398850] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 01/14/2023] [Indexed: 02/05/2023] Open
Abstract
Purpose Pneumocystis jirovecii pneumonia (PJP) is an opportunistic but potentially fatal infection with increasing prevalence in HIV-free patients. Glucocorticoid therapy is one of the most important risk factors for PJP. The delay in diagnosis contributes to poor outcomes. Hence, the aim of this study was to develop and validate a nomogram for the diagnosis of PJP in patients with non-HIV-infected pneumonia who are undergoing oral glucocorticoid treatment. Patients and Methods This study was a retrospective, cross-sectional research. The development group included 434 patients who were admitted with pneumonia from 6 hospitals. Demographics, symptomatic features, laboratory and computed tomography data were analyzed using the least absolute shrinkage and selection operator (LASSO) to select potential diagnostic indicators. Binary logistic regression was used to develop a diagnostic nomogram. Another 119 patients with pneumonia admitted at Sichuan Provincial People's Hospital was used as the validation group. The diagnostic performance of the nomogram was measured by area under the receiver-operating-characteristics curve (AUC), calibration curves, and the net benefit by decision curve. Results PJP prevalence was 25.3% in the development group. LASSO regression revealed that age, lymphocyte count, fever, dry cough, respiratory failure, ground-glass opacity in lungs, glucocorticoid therapy duration, and immunosuppressive therapy were indicators of PJP. The nomogram showed robust discrimination, with an AUC of 0.82 (95% CI 0.77-0.86) in the development group and an AUC of 0.87 (95% CI 0.80-0.94) in the validation group, both showing acceptable calibration. In the decision curve analysis, our model consistently achieved a greater net benefit across almost all ranges of clinical thresholds. Conclusion We developed a nomogram with good diagnostic power for PJP diagnosis in pneumonia patients receiving oral glucocorticoids. This nomogram may help promote timely treatment of PJP and thus reduce the mortality rate in these patients.
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Affiliation(s)
- Qin Lang
- Department of Pulmonary and Critical Care Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, 610000, People’s Republic of China,Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610000, People’s Republic of China
| | - Lijuan Li
- National Clinical Research Centre for Respiratory Diseases, China-Japan Friendship Hospital, Capital Medical University, Beijing, 100000, People’s Republic of China
| | - Yue Zhang
- Department of Nephrology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, 610000, People’s Republic of China
| | - Xing He
- School of Clinical Medicine, Chengdu Medical College, Chengdu, 610000, People’s Republic of China
| | - Yafeng Liu
- School of Medicine, Anhui University of Science and Technology, Huainan, 232000, People’s Republic of China,Anhui Province Engineering Laboratory of Occupational Health and Safety, Huainan, 232000, People’s Republic of China
| | - Zhen Liu
- The First Hospital of Liangshan Prefecture, Xichang, 615000, People’s Republic of China
| | - Haiying Yan
- Department of Pulmonary and Critical Care Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, 610000, People’s Republic of China,Department of Pulmonary and Critical Care Medicine, Chengdu Qing Cheng Mt. Hospital, Chengdu, 610000, People’s Republic of China,Correspondence: Haiying Yan, Department of Pulmonary and Critical Care Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Sec 2, 1st Ring Road, Chengdu, Sichuan, 610000, People’s Republic of China, Tel/Fax +86-18981838295, Email
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Clinical characteristics of and risk factors for Pneumocystis jirovecii pneumonia in anti-melanoma differentiation-associated gene 5 (Anti-MDA5) antibody-positive dermatomyositis patients: a single-center retrospective study. Clin Rheumatol 2023; 42:453-462. [PMID: 36301369 DOI: 10.1007/s10067-022-06403-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 09/04/2022] [Accepted: 10/04/2022] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Pneumocystis jirovecii pneumonia (PJP) is a serious opportunistic infection mainly diagnosed in patients with rheumatic conditions. However, PJP in anti-melanoma differentiation-associated gene 5-positive dermatomyositis (MDA5 + DM) patients remains poorly understood. We aimed to investigate the 6-month PJP risk in newly diagnosed MDA5 + DM patients. METHODS A retrospective observational study of 105 inpatients with newly diagnosed MDA5 + DM was conducted at Renji Hospital from January 2018 to November 2019. Demographic information, clinical characteristics, and treatment data were recorded. The primary outcome was PJP incidence within 6 months after a MDA5 + DM diagnosis. RESULTS The analysis included 105 patients, including 13 patients diagnosed with PJP during the observation period. The median time from the MDA5 + DM diagnosis to PJP was 89 ± 38 days. Compared with the PJP - patients, the PJP + patients had a significantly greater risk of mortality (69.2% vs. 13.0% P < 0.001). Regarding the baseline comorbidities, hypertension (P = 0.013) and cancer (P = 0.02) were more common in the PJP + group. Additionally, a larger proportion of the PJP + patients received prolonged high-dose steroid therapy (≥ 60 mg/day and ≥ 1 month) (P = 0.022) and double or triple immunosuppressant therapy (P = 0.013). The multivariate analysis showed that PJP was independently associated with lymphopenia (ALC < 500 cells/µl) (OR: 5.434, 95% CI: 2.074-55.155; P = 0.012) and the combined use of cyclophosphamide (CTX) and tacrolimus (TAC) (OR: 10.695, 95% CI: 1.440-20.508; P = 0.005). CONCLUSION There was a high incidence and mortality in the MDA5 + DM patients with PJP, with patients on combined immunosuppressive treatments, particularly CTX and TAC, being at a higher risk. Prolonged high-dose steroid therapy (≥ 60 mg/day and ≥ 1 month) was another risk factor for PJP. Key Points • There was a high incidence and mortality in the MDA5 + DM patients with PJP. • Most PJP cases occurred within 3 months after the MDA5 + DM diagnosis. • The 6-month infection risk of PJP increased with the administration of multiagent immunosuppression, especially the combination of CTX and TAC. • Prolonged high-dose steroid therapy (≥ 60 mg/day and ≥ 1 month) was another risk factor for PJP.
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Nunokawa T, Chinen N, Shimada K, Kimura M, Tateishi M, Chen FY, Setoguchi K, Sugihara M. Efficacy of sulfasalazine for the prevention of Pneumocystis pneumonia in patients with rheumatoid arthritis: A multicentric self-controlled case series study. J Infect Chemother 2023; 29:193-197. [PMID: 36334836 DOI: 10.1016/j.jiac.2022.10.019] [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: 08/25/2022] [Revised: 10/24/2022] [Accepted: 10/30/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Pneumocystis pneumonia (PCP) is an opportunistic lung infection and has been reported among patients with rheumatoid arthritis (RA). An animal study revealed that sulfasalazine enhances Pneumocystis clearance from the lung by accelerating macrophage activity. METHODS The self-controlled case series (SCCS) method was used to investigate the association between sulfasalazine use and PCP development in patients with RA without the effect of time-invariant, interpatient confounders. PCP episodes which developed in patients with RA at five hospitals between 2003 and 2019 were identified. PCP was defined by the following criteria: 1) detection of Pneumocystis jirovecii in respiratory specimens by polymerase chain reaction; 2) clinical symptoms (pyrexia, dry cough, dyspnea or hypoxia); 3) diffuse interstitial infiltrate on chest imaging; and 4) absence of PCP prophylaxis. The PCP incidence rate ratio (IRR) was compared between periods with and without sulfasalazine use by conditional Poisson regression. RESULTS Fifty episodes of PCP were identified in 49 patients. Thirty patients received sulfasalazine at some point during their observation. While 49 episodes of PCP developed in 170.3 person-years without sulfasalazine use, only one episode of PCP developed in 103.7 person-years with sulfasalazine use. Sulfasalazine use was associated with a decreased PCP risk (adjusted IRR <0.01; 95% confidence interval <0.01-0.03) after adjusting for age and glucocorticoid, methotrexate, and tumor necrosis factor inhibitor administration. CONCLUSION Our study demonstrated a preventive effect of sulfasalazine against PCP in patients with RA.
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Affiliation(s)
- Takahiro Nunokawa
- Department of Rheumatic Diseases, Tama-Namub Chiiki Hosipital, 2-1-2, Nakazawa, Tama-shi, Tokyo, Japan; Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, 2-8-29, Musashidai, Fuchu-shi, Tokyo, Japan.
| | - Naofumi Chinen
- Department of Rheumatic Diseases, Tama-Namub Chiiki Hosipital, 2-1-2, Nakazawa, Tama-shi, Tokyo, Japan.
| | - Kota Shimada
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, 2-8-29, Musashidai, Fuchu-shi, Tokyo, Japan.
| | - Makiko Kimura
- Department of Rheumatology, Tokyo Metropolitan Ohtsuka Hospital, 2-8-1, Minamiohtsuka, Toshima-ku, Tokyo, Japan.
| | - Mutsuto Tateishi
- Department of Rheumatology, Tokyo Metropolitan Ohtsuka Hospital, 2-8-1, Minamiohtsuka, Toshima-ku, Tokyo, Japan.
| | - Fang Yi Chen
- Department of Rheumatology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22, Honkomagome, Bunkyo-ku, Tokyo, Japan.
| | - Keigo Setoguchi
- Department of Rheumatology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22, Honkomagome, Bunkyo-ku, Tokyo, Japan.
| | - Makoto Sugihara
- Department of Rheumatic Diseases, Tama-Hokubu Medical Center, 1-7-1 Aoba-cho, Higashimurayama-shi, Tokyo, Japan.
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Anumolu N, Henry K, Sattui SE, Putman M. Is there a role for Pneumocystis jiroveci pneumonia prophylaxis in giant cell arteritis or polymyalgia rheumatica? Semin Arthritis Rheum 2023; 58:152154. [PMID: 36563422 DOI: 10.1016/j.semarthrit.2022.152154] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/26/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Pneumocystis jiroveci pneumonia (PJP) is an opportunistic fungal infection that affects immunocompromised patients. The objective of this study was to describe the incidence of PJP among patients with giant cell arteritis (GCA) or polymyalgia rheumatica (PMR). METHODS A retrospective cohort study of incident cases of GCA and PMR was conducted using claims data from the TriNetX database to describe the incidence of PJP during the first 6 months of therapy. Additionally, a systematic review was performed to identify other publications describing PJP among patients with GCA or PMR. RESULTS During 547 patient-years of follow-up time, no cases of PJP were identified among 1,168 cases of GCA (incident rate 0 per 1,000 person-years); during 7,446 patient-years of follow up time, one case of PJP was identified out of 15,575 cases of PMR (incident rate 0.07 cases per 1,000 patient-years). This patient was alive at last follow up. Our systematic review identified 1 case-control study, 4 cohort studies, and 18 case series / case reports of PJP among patients with GCA or PMR. The incident rate of PJP was reported from one additional study for GCA and was estimated at 0.08 cases per 1,000 person years; no additional cohort studies were identified for patients with PMR. Over the entirety of the published literature, the total number of cases identified among case series and case reports was 33, from which 4 total deaths were identified. CONCLUSIONS Patients with newly diagnosed GCA or PMR rarely develop PJP. Existing data does not support routine prescribing of PJP prophylaxis for either group of patients.
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Affiliation(s)
- Natalie Anumolu
- Hub for Collaborative Medicine, Medical College of Wisconsin, 8701 Watertown Plank Rd, Rheumatology 8th Floor, Milwaukee, WI, United States.
| | - Katie Henry
- Hub for Collaborative Medicine, Medical College of Wisconsin, 8701 Watertown Plank Rd, Rheumatology 8th Floor, Milwaukee, WI, United States
| | | | - Michael Putman
- Hub for Collaborative Medicine, Medical College of Wisconsin, 8701 Watertown Plank Rd, Rheumatology 8th Floor, Milwaukee, WI, United States.
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Odler B, Riedl R, Gauckler P, Shin JI, Leierer J, Merkel PA, St Clair W, Fervenza F, Geetha D, Monach P, Jayne D, Smith RM, Rosenkranz A, Specks U, Stone JH, Kronbichler A. Risk factors for serious infections in ANCA-associated vasculitis. Ann Rheum Dis 2023; 82:681-687. [PMID: 36702528 PMCID: PMC10176387 DOI: 10.1136/ard-2022-223401] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 01/06/2023] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Severe infections contribute to morbidity and mortality in antineutrophil cytoplasm antibody-associated vasculitis (AAV). This study aimed to identify risk factors associated with severe infections in participants of the Rituximab versus Cyclophosphamide for ANCA-Associated Vasculitis (RAVE) trial. METHODS Data on 197 patients recruited into the RAVE trial were analysed. Participants received either rituximab (RTX) or cyclophosphamide (CYC), followed by azathioprine (AZA). Clinical and laboratory data of patients with and without severe infections (≥grade 3, according to the Common Terminology Criteria for Adverse Events version 3.0) were compared. Risk factors for severe infections were investigated using Cox-regression models. RESULTS Eighteen of 22 (82%) severe infections occurred within 6 months after trial entry, most commonly respiratory tract infections (15/22, 68%). At baseline, lower absolute numbers of CD19+ cells were observed in patients with severe infections either receiving RTX or CYC/AZA at baseline, while CD5+B and CD3+T cells did not differ between groups. In Cox-regression analysis, higher baseline serum immunoglobulin M levels were associated with the risk of severe infections, whereby a higher baseline total CD19+B cell number and prophylaxis against Pneumocystis jirovecii with trimethoprim-sulfamethoxazole (TMP/SMX) with decreased risk of severe infections. Use of TMP/SMX was associated with lower risk of severe infections in both groups, receiving either RTX or CYC/AZA. CONCLUSIONS The use of low-dose TMP/SMX is associated with reduced risk of severe infections in patients with AAV treated with either RTX or CYC/AZA. Reduced B cell subpopulations at start of treatment might be a useful correlate of reduced immunocompetence.
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Affiliation(s)
- Balazs Odler
- Department of Medicine, University of Cambridge, Cambridge, UK.,Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Regina Riedl
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Philipp Gauckler
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
| | - Jae Il Shin
- Yonsei University College of Medicine and Severance Children's Hospital, Seoul, Republic of Korea
| | - Johannes Leierer
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
| | - Peter A Merkel
- Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - William St Clair
- Division of Rheumatology and Immunology, Duke University, Durham, North Carolina, USA
| | - Fernando Fervenza
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Duvuru Geetha
- Division of Nephrology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Paul Monach
- VA Boston Healthcare System, West Roxbury, Massachusetts, USA
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Rona M Smith
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Alexander Rosenkranz
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - John H Stone
- Division of Rheumatology Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Kim KN, LaRiviere M, Macduffie E, White CA, Jordan-Luft MM, Anderson E, Ziegler M, Radcliff JA, Jones J. Use of Glucocorticoids in Patients With Cancer: Potential Benefits, Harms, and Practical Considerations for Clinical Practice. Pract Radiat Oncol 2023; 13:28-40. [PMID: 35917896 DOI: 10.1016/j.prro.2022.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/13/2022] [Accepted: 07/22/2022] [Indexed: 01/10/2023]
Abstract
PURPOSE Glucocorticoids are commonly used in patients with cancer for symptom relief or as part of their anticancer treatment. Despite their frequent use, indications and dosing regimens are not exclusively evidence-based and can come with a multitude of adverse effects, some of which can be life-threatening. The objective of this review is to update our current state of knowledge on the use of glucocorticoids in adult patients with cancer. METHODS AND MATERIALS A comprehensive literature review (1949-2022) was conducted using search terms "glucocorticoids," "corticosteroids," and "cancer." Information was organized by main concepts including indications, potential benefits, and prevention and management of common side effects of glucocorticoid therapy, in addition to appropriate dosing and taper regimens. RESULTS Glucocorticoids can be highly effective in improving outcomes and quality of life in patients with cancer. Their uses include management of disease manifestations, symptoms, and complications of cancer treatment. The lowest effective dose should be used and treatment duration should be minimized as clinically feasible. Side effects can be minimized by careful monitoring, continued assessment of benefits versus harms, and preventative measures for expected side effects. CONCLUSIONS This review provides general principles and practical recommendations on the use of glucocorticoids in patients with cancer. Further prospective studies on the outcomes of patients on glucocorticoids may help guide practice.
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Affiliation(s)
- Kristine N Kim
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
| | - Michael LaRiviere
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Emily Macduffie
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Caitlin A White
- Department of Medicine, Division of Endocrinology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Mary M Jordan-Luft
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Eleanor Anderson
- Department of Psychiatry, Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Matthew Ziegler
- Department of Medicine, Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jacob A Radcliff
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua Jones
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Wang H, Shui L, Chen Y. Combine use of glucocorticoid with other immunosuppressants is a risk factor for Pneumocystis jirovecii pneumonia in autoimmune inflammatory disease patients: a meta-analysis. Clin Rheumatol 2023; 42:269-276. [PMID: 36149536 DOI: 10.1007/s10067-022-06381-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 08/16/2022] [Accepted: 09/16/2022] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To determine whether the combined use of glucocorticoid with other immunosuppressants increased the risk of Pneumocystis jirovecii pneumonia (PCP) in autoimmune inflammatory disease (AIID) patients. METHODS The data were collected from the PubMed, Cochrane Library, and Web of Science databases. We excluded HIV-infected patients and those < 16 years of age, and included patients who combined use of glucocorticoid with other immunosuppressants or used glucocorticoid alone. The number of patients who were affected by PCP after therapy as the primary outcome and the number of patients with fatal outcomes, which included death, endotracheal tube intubation, PO2 < 60 mmHg, and other serious clinical symptoms due to PCP, as the secondary outcome. Odds ratios with 95% confidence intervals and variance tests were used to analyze the data. RESULTS The outcomes showed that the combined use of glucocorticoid with other immunosuppressants increased the risk of PCP in AIID patients (odds ratio = 2.85, 95% confidence intervals 1.75 to 4.64, I2 = 0%, P < 0.0001), which may be a consequence of the drug regimen reducing the lymphocyte count. Furthermore, the prognosis of patients receiving this drug regimen was poorer than with glucocorticoid alone (odds ratio = 2.31, 95% confidence intervals 1.02 to 5.23, I2 = 0%, P = 0.04). CONCLUSION The combined use of glucocorticoid with other immunosuppressants increased the risk of PCP in AIID patients and resulted in poorer prognoses. It is therefore clear that appropriate prophylaxis was vital in AIID patients to minimize the risk of PCP. Key Points • We demonstrated that the combined use of glucocorticoid with other immunosuppressants increased the risk of PCP in AIID patients and resulted in poorer prognoses. • As there are no standard prophylactic guidelines, we wish this work will be evidence to guide clinical prophylaxis.
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Affiliation(s)
- Huyu Wang
- Department of Chongqing Medical University, Chongqing, 400016, China
| | - Lili Shui
- Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Yajuan Chen
- Department of Chongqing Medical University, Chongqing, 400016, China. .,Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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Song S, Zhang Y, Yu J, Xie C, Chen Y, Zhang X. Time to trimethoprim/sulfamethoxazole initiation among patients with rheumatic disease complicated by Pneumocystis jirovecii pneumonia: impact on 90-day mortality. BMC Infect Dis 2022; 22:961. [PMID: 36575406 PMCID: PMC9793549 DOI: 10.1186/s12879-022-07940-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 12/12/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PJP) is a life-threatening disease with increasing prevalence in patients with rheumatic disease. Trimethoprim/sulfamethoxazole (TMP/SMX) is an effective treatment for patients with rheumatic disease hospitalized for PJP. This study aimed to describe the 90-day mortality of patients with rheumatic disease complicated by PJP and investigate whether the administration of TMP/SMX after 7 days from initial symptoms correlates with 90-day mortality. METHODS We enrolled consecutive patients with rheumatic disease complicated with PJP in our center from August 2018 to August 2021. The participants were classified into two groups according to when TMP/SMX was initiated: early (within the first 7 days) and late (after 7 days). The primary outcome was 90-day PJP-related mortality. Multivariate cox regression and Kaplan-Meier survival analyses were conducted to identify the risk factors for mortality and examine differences in survival between early and late use of TMP/SMX. RESULTS Thirty-seven patients with rheumatic disease (median age 50.1 years, 24.3% male) complicated by PJP were enrolled in our study, and 15 (40.5%) patients died at or before 90 days of follow-up. The most common comorbidity was systemic lupus erythematosus (14, 37.8%), followed by inflammatory myopathy (11, 27.9%). Patients in the early group were less likely to require mechanical ventilation (8/27, 29.6% vs. 9/10, 90.0%, P = 0.002), lower doses glucocorticoids (43.2 mg/d vs. 72.2 mg/d, P = 0.039) and had lower mortality (7/27, 25.9% vs. 8/10, 80.0%, P = 0.006) than those in the late group. In the Kaplan-Meier analysis, the survivor probability of the early group was notably higher than that of the late group (P = 0.007). Multivariate cox regression analysis showed that initiation of TMP/SMX after 7 days from admission (hazard ratio [HR]: 5.9, 95% confidence interval [CI]: 1.1-30.4; P = 0.034) and a higher level of lactate dehydrogenase (LDH; HR: 6.0, 95% CI: 1.1-31.8; P = 0.035) were associated with 90-day mortality in patients with rheumatic disease complicated by PJP. CONCLUSION Patients with rheumatic disease complicated by PJP had poor prognoses, with mortality rates as high as 40.5%. TMP/SMX initiation after 7 days from initial symptoms and a higher level of serum LDH were significantly associated with increased 90-day mortality.
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Affiliation(s)
- Siyang Song
- grid.415869.7Department of Emergency, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai, China
| | - Yang Zhang
- grid.415869.7Department of Emergency, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai, China
| | - Jie Yu
- grid.415869.7Department of Emergency, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai, China
| | - Cuiying Xie
- grid.415869.7Department of Emergency, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai, China
| | - Yi Chen
- grid.415869.7Department of Emergency, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai, China
| | - Xingyu Zhang
- grid.415869.7Department of Emergency, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai, China
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Boone B, Lazaroff SM, Wheless L, Wolfe RM, Barnado A. Rates of Pneumocystis jirovecii pneumonia and prophylaxis prescribing patterns in a large electronic health record cohort of patients with systemic lupus erythematosus. Semin Arthritis Rheum 2022; 57:152106. [PMID: 36279805 PMCID: PMC9937021 DOI: 10.1016/j.semarthrit.2022.152106] [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: 06/24/2022] [Revised: 09/22/2022] [Accepted: 10/10/2022] [Indexed: 11/07/2022]
Abstract
Objective No guidelines exist for Pneumocystis jirovecii pneumonia (PJP) prophylaxis in patients with systemic lupus erythematosus (SLE). Limited data are available on incidence of PJP infection and use of PJP prophylaxis. Using a real-world, electronic health record (EHR) cohort, we investigated the frequency of PJP infections as well as patient and provider factors that impacted use and type of PJP prophylaxis. Methods In a large, de-identified EHR, we identified possible SLE patients using a previously validated algorithm. PJP ICD-9 or ICD-10-CM billing codes and PJP keywords were used to identify possible PJP cases within this SLE cohort. We assessed for PJP prophylaxis prescribing in all SLE patients using keywords and reviewing medication lists for prophylactic agents. Chart review was used to confirm cases of SLE, PJP, and PJP prophylaxis and to obtain data on demographics, comorbidities, and immunosuppressants. Results Of 977 SLE patients, there were only four with confirmed PJP infection. Two of these patients had concurrent Acquired Immunodeficiency Syndrome, and none were on prophylaxis. Of 977 SLE patients, 132 (14%) were prescribed PJP prophylaxis. Of 617 SLE patients ever prescribed immunosuppressants, 128 (21%) were prescribed PJP prophylaxis. Sulfonamides were the most common prophylaxis prescribed (69%), and possible adverse events were documented in 22 out of 117 instances of being placed on a sulfonamide. Patients of younger age, Black race, nephritis, and renal transplant, and on chronic glucocorticoids were all more likely to have PJP prophylaxis prescribed. Patients who were on transplant induction medications, calcineurin/mTOR inhibitors, cyclophosphamide, and mycophenolate mofetil all were more likely to be prescribed PJP prophylaxis compared to other immunosuppressants. Conclusion PJP is a rare diagnosis among SLE patients, and prior studies may even overestimate its prevalence. PJP prophylaxis was less common in our cohort than previously described. Adverse events related to sulfonamides used for PJP prophylaxis were relatively rare with lower rates than previously reported. Our study demonstrates real-world PJP prophylaxis prescribing patterns in a large cohort of SLE patients.
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Affiliation(s)
- Ben Boone
- Department of Medicine, Division of Rheumatology, Vanderbilt University Medical Center, 1161 21st Avenue South T-3113 Medical Center North, Nashville, TN 37232-2681, United States
| | - Samuel M Lazaroff
- Department of Medicine, Division of Rheumatology, Vanderbilt University Medical Center, 1161 21st Avenue South T-3113 Medical Center North, Nashville, TN 37232-2681, United States
| | - Lee Wheless
- Department of Dermatology, Division of Epidemiology, Vanderbilt University Medical Center, 719 Thompson Lane, Suite 26300, Nashville, TN 37204, United States
| | - Rachel M Wolfe
- Department of Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC 27157, United States
| | - April Barnado
- Department of Medicine, Division of Rheumatology, Vanderbilt University Medical Center, 1161 21st Avenue South T-3113 Medical Center North, Nashville, TN 37232-2681, United States; Department of Biomedical Informatics, Vanderbilt University Medical Center, 2525 West End Ave # 1475, Nashville, TN 37203, United States.
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Ssebambulidde K, Anjum SH, Hargarten JC, Chittiboina P, Shoham S, Seyedmousavi S, Marr KA, Hammoud DA, Billioux BJ, Williamson PR. Treatment recommendations for non-HIV associated cryptococcal meningoencephalitis including management of post-infectious inflammatory response syndrome. Front Neurol 2022; 13:994396. [PMID: 36530631 PMCID: PMC9751747 DOI: 10.3389/fneur.2022.994396] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 11/04/2022] [Indexed: 08/29/2023] Open
Abstract
Cryptococcal meningoencephalitis (CM) continues to cause major morbidity and mortality in a range of patients such as those immunosuppressed from HIV and with biologic immunosuppressants, including treatments of autoimmunity, malignancies, and conditioning regimens for transplantation. It is currently the most common cause of non-viral meningitis in the United States. Infections in previously healthy patients also develop with autoantibodies to granulocyte-macrophage colony stimulating factor or with monogenetic defects. In all populations, mortality and significant long-term morbidity occur in 30-50% despite therapy, and immune reconstitution and post-infectious inflammatory response syndromes complicate management. To help with these difficult cases, we present here a practical tutorial of the care of a range of patients with CM in the absence of HIV/AIDS.
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Affiliation(s)
- Kenneth Ssebambulidde
- Translational Mycology Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Seher H. Anjum
- Translational Mycology Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Jessica C. Hargarten
- Translational Mycology Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Prashant Chittiboina
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
| | - Shmuel Shoham
- Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Seyedmojtaba Seyedmousavi
- Microbiology Service, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Kieren A. Marr
- Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Dima A. Hammoud
- Center for Infectious Disease Imaging (CIDI), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Bridgette Jeanne Billioux
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Peter R. Williamson
- Translational Mycology Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
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Jin F, Liang H, Chen WC, Xie J, Wang HL. Development and validation of tools for predicting the risk of death and ICU admission of non-HIV-infected patients with Pneumocystis jirovecii pneumonia. Front Public Health 2022; 10:972311. [PMID: 36424963 PMCID: PMC9679649 DOI: 10.3389/fpubh.2022.972311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 09/29/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction The mortality rate of non-HIV-infected Pneumocystis jirovecii pneumonia (PCP) is high. This research aimed to develop and validate two clinical tools for predicting the risk of death and intensive care unit (ICU) admission in non-HIV-infected patients with PCP to reduce mortality. Methods A retrospective study was conducted at Peking Union Medical College Hospital between 2012 and 2021. All proven and probable non-HIV-infected patients with PCP were included. The least absolute shrinkage and selection operator method and multivariable logistic regression analysis were used to select the high-risk prognostic parameters. In the validation, the receiver operating characteristic curve and concordance index were used to quantify the discrimination performance. Calibration curves were constructed to assess the predictive consistency compared with the actual observations. A likelihood ratio test was used to compare the tool and CURB-65 score. Results In total, 508 patients were enrolled in the study. The tool for predicting death included eight factors: age, chronic lung disease, respiratory rate, blood urea nitrogen (BUN), lactate dehydrogenase (LDH), cytomegalovirus infection, shock, and invasive mechanical ventilation. The tool for predicting ICU admission composed of the following factors: respiratory rate, dyspnea, lung moist rales, LDH, BUN, C-reactive protein/albumin ratio, and pleural effusion. In external validation, the two clinical models performed well, showing good AUCs (0.915 and 0.880) and fit calibration plots. Compared with the CURB-65 score, our tool was more informative and had a higher predictive ability (AUC: 0.880 vs. 0.557) for predicting the risk of ICU admission. Conclusion In conclusion, we developed and validated tools to predict death and ICU admission risks of non-HIV patients with PCP. Based on the information from the tools, clinicians can tailor appropriate therapy plans and use appropriate monitoring levels for high-risk patients, eventually reducing the mortality of those with PCP.
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Affiliation(s)
- Fan Jin
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hao Liang
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wen-can Chen
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Xie
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huan-ling Wang
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China,Clinical Pharmacology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China,Department State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China,*Correspondence: Huan-ling Wang
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Fragoulis GE, Nikiphorou E, Dey M, Zhao SS, Courvoisier DS, Arnaud L, Atzeni F, Behrens GM, Bijlsma JW, Böhm P, Constantinou CA, Garcia-Diaz S, Kapetanovic MC, Lauper K, Luís M, Morel J, Nagy G, Polverino E, van Rompay J, Sebastiani M, Strangfeld A, de Thurah A, Galloway J, Hyrich KL. 2022 EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in adults with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis 2022; 82:742-753. [PMID: 36328476 DOI: 10.1136/ard-2022-223335] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022]
Abstract
ObjectivesTo develop EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in patients with autoimmune inflammatory rheumatic diseases (AIIRD).MethodsAn international Task Force (TF) (22 members/15 countries) formulated recommendations, supported by systematic literature review findings. Level of evidence and grade of recommendation were assigned for each recommendation. Level of agreement was provided anonymously by each TF member.ResultsFour overarching principles (OAP) and eight recommendations were developed. The OAPs highlight the need for infections to be discussed with patients and with other medical specialties, in accordance with national regulations. In addition to biologic/targeted synthetic disease-modifying antirheumatic drugs (DMARDs) for which screening for latent tuberculosis (TB) should be performed, screening could be considered also before conventional synthetic DMARDs, glucocorticoids and immunosuppressants. Interferon gamma release assay should be preferred over tuberculin skin test, where available. Hepatitis B (HBV) antiviral treatment should be guided by HBV status defined prior to starting antirheumatic drugs. All patients positive for hepatitis-C-RNA should be referred for antiviral treatment. Also, patients who are non-immune to varicella zoster virus should be informed about the availability of postexposure prophylaxis should they have contact with this pathogen. Prophylaxis againstPneumocystis jiroveciiseems to be beneficial in patients treated with daily doses >15–30 mg of prednisolone or equivalent for >2–4 weeks.ConclusionsThese recommendations provide guidance on the screening and prevention of chronic and opportunistic infections. Their adoption in clinical practice is recommended to standardise and optimise care to reduce the burden of opportunistic infections in people living with AIIRD.
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Affiliation(s)
- George E Fragoulis
- Joint Academic Rheumatology Program, First Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, King's College London, London, UK
- Rheumatology Department, King's College London, London, UK
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Rheumatology Department, Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Sizheng Steven Zhao
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Science, The University of Manchester, Manchester, UK
| | | | - Laurent Arnaud
- Department of Rheumatology, National Reference Center for Autoimmune Diseases (RESO), University Hospitals Strasbourg, Strasbourg, France
| | - Fabiola Atzeni
- Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, Messina, Italy
| | - Georg Mn Behrens
- Department for Rheumatology and Immunology, Hannover Medical School, Hannover, Germany
| | - Johannes Wj Bijlsma
- Dept of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Peter Böhm
- Forschungspartner, German League against rheumatism, Bonn, Germany
| | | | - Silvia Garcia-Diaz
- Rheumatology Department, Complex Hospitalari Moises Broggi, Barcelona, Spain
| | | | - Kim Lauper
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Science, The University of Manchester, Manchester, UK
- Division of Rheumatology, University of Geneva, Geneva, Switzerland
| | - Mariana Luís
- Rheumatology, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Jacques Morel
- Department of Rheumatology, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - György Nagy
- Department of Rheumatology and Clinical Immunology, Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Department of Genetics, Cell- and Immunobiology, Semmelweis University, Budapest, Hungary
| | - Eva Polverino
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Ciber de Enfermedades Respiratorias CIBERES, Barcelona, Spain
| | - Jef van Rompay
- Belgium Patient Partner Program, EULAR People with Arthritis/Rheumatism across Europe (PARE), Antwerpen, Belgium
| | - Marco Sebastiani
- Rheumatology Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Anja Strangfeld
- Epidemiology and Health Services Research, German Rheumatism Research Centre (DRFZ) Berlin and Charite University Medicine, Berlin, Germany
| | - Annette de Thurah
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - James Galloway
- Centre for Rheumatic Diseases, King's College London, London, UK
- Rheumatology Department, King's College London, London, UK
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Science, The University of Manchester, Manchester, UK
- National Institute of Health Research Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester NHS Foundation Trust, Manchester, UK
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Fragoulis GE, Dey M, Zhao S, Schoones J, Courvoisier D, Galloway J, Hyrich KL, Nikiphorou E. Systematic literature review informing the 2022 EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in adults with autoimmune inflammatory rheumatic diseases. RMD Open 2022; 8:rmdopen-2022-002726. [PMID: 36323488 PMCID: PMC9639159 DOI: 10.1136/rmdopen-2022-002726] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 10/12/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To conduct a systematic literature review (SLR) on the screening and prophylaxis of opportunistic and chronic infections in autoimmune inflammatory rheumatic diseases (AIIRD). METHODS SLR (inception-12/2021) based on the following search domains: (1) infectious agents, (2) AIIRD, (3) immunosuppressives/immunomodulators used in rheumatology, (4) screening terms and (5) prophylaxis terms. Articles were retrieved having the terms from (1) AND (2) AND (3) plus terms from (4) OR(5). Databases searched: PubMed, Embase and Cochrane Library. EXCLUSION CRITERIA studies on postoperative infections, paediatric AIIRD, COVID-19, vaccinations and non-Εnglish literature. Study quality was assessed with Newcastle-Ottawa scale for non-randomised controlled trials (RCTs), RoB-Cochrane for RCTs, AMSTAR2 for SLRs. RESULTS From 5641 studies were retrieved, 568 full-text articles were assessed for eligibility, with 194 articles finally included. For tuberculosis, tuberculin skin test (TST) is affected by treatment with glucocorticoids and conventional synthetic disease modifying anti-rheumatic drugs (DMARDs) and its performance is inferior to interferon gamma release assay (IGRA). Agreement between TST and IGRA is moderate to low. For hepatitis B virus (HBV): risk of reactivation is increased in patients positive for hepatitis B surface antigen. Anti-HBcore positive patients are at low risk for reactivation but should be monitored periodically with liver function tests and/or HBV-viral load. Risk for Hepatitis C reactivation is existing but low in patients treated with biological DMARDs. For Pneumocystis jirovecii, prophylaxis treatment should be considered in patients treated with prednisolone ≥15-30 mg/day for >2-4 weeks. CONCLUSIONS Different screening and prophylaxis approaches are described in the literature, partly determined by individual patient and disease characteristics.
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Affiliation(s)
- George E Fragoulis
- Joint Academic Rheumatology Program, National and Kapodistrian University of Athens, First Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Rheumatology, Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Sizheng Zhao
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
| | - Jan Schoones
- Directorate of Research Policy, Leiden University Medical Center, Leiden, The Netherlands
| | | | - James Galloway
- Centre for Rheumatic Diseases, King's College London, London, UK
- Rheumatology Department, King's College London, London, UK
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
- National Institute of Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, King's College London, London, UK
- Rheumatology Department, King's College London, London, UK
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Abstract
This review aims to describe the epidemiology, pathogenesis, clinical manifestations, diagnosis, treatment, and prognosis of eosinophilic granulomatosis with polyangiitis (EGPA). Eosinophilic granulomatosis with polyangiitis is a small to medium vessel necrotizing vasculitis, typically classified with granulomatosis with polyangiitis (GPA) and microscopic polyangitis (MPA) as antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). However, less than 50% of patients with EGPA have a positive ANCA test. Among all the vasculitides, asthma and eosinophilia are unique features of EGPA. Eosinophilic granulomatosis with polyangiitis is very rare and the diagnosis may be missed as the disease evolves over time. Polyneuropathies are common and may be severe, requiring aggressive immunosuppressive therapy. Heart involvement is the most common cause of death in EGPA. Biopsy of involved tissue supports a clinically suspected diagnosis but is not always feasible. Treatment of EGPA is primarily dictated by the severity of disease and prognostic factors. More severe disease frequently requires the use of aggressive therapy such as cyclophosphamide. Once treatment is initiated, patients can achieve good control of symptoms; unfortunately, disease relapses are common and prolonged treatment with corticosteroids is often necessary for asthma management. A better understanding of the disease heterogeneity is needed for the development of better therapies.
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Affiliation(s)
- Alexandra Villa-Forte
- Cleveland Clinic - Center for Vasculitis Care and Research, Department of Rheumatic and Immunologic Diseases 9500 Euclid Ave/A50 Cleveland Ohio 44195-5243, USA
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Nasr M, Mohammad A, Hor M, Baradeiya AM, Qasim H. Exploring the Differences in Pneumocystis Pneumonia Infection Between HIV and Non-HIV Patients. Cureus 2022; 14:e27727. [PMID: 36106266 PMCID: PMC9441775 DOI: 10.7759/cureus.27727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 11/06/2022] Open
Abstract
Pneumocystis pneumonia (PCP) is one of the most common opportunistic infections worldwide that affects the lung. Pneumocystis leads to pneumonia, caused by Pneumocystis jirovecii, formerly known as Pneumocystis carinii. In recent decades, PCP has been a major health problem for human immunodeficiency virus (HIV) patients and is responsible for most of mortality and morbidity. However, the increasing number of immunosuppressive-related diseases has led to outbreaks in other patient populations, raising the concern for PCP as it becomes a major concern among those patients. These changes led to marked changes in the prevalence and mortality rates of PCP. Huge variations in those parameters among HIV and non-HIV patients have been seen also. Historically, the diagnosis was made by staining and direct visualization of the organism within the bronchoalveolar lavage (BAL) fluid. The diagnosis is now made by microscopic examination and a real-time polymerase chain reaction (PCR) of BAL. Serum (1,3)-β-D-glucan, which is a component of the Pneumocystis jirovecii cell wall that distinguishes it from other fungi, has become an important diagnostic tool. Early diagnosis and treatment play a vital role in the patient’s survival and in the infection outcome; hence, empirical PCP therapy should be started immediately when the infection is suspected without waiting for the results of the diagnostic test. Steroids play an important role in the treatment of HIV patients, especially patients who present with hypoxia and respiratory failure. Prophylaxis is very effective and should be given to all patients at high risk of PCP. Antiretroviral therapy (ART) should be started as soon as possible in newly diagnosed HIV-infected patients with PCP, and the immune status of immunocompromised patients with PCP should be improved by temporarily withholding immunosuppressive drugs or reducing their doses.
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Borojevic B, Johns E, Raju N, Sycamnias LA. Pneumocystis pneumonia with respiratory failure in a HIV-negative patient following short course of low-dose to moderate-dose prednisolone for a dermatological condition. BMJ Case Rep 2022; 15:e249346. [PMID: 35675962 PMCID: PMC9185496 DOI: 10.1136/bcr-2022-249346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2022] [Indexed: 12/15/2022] Open
Abstract
A woman in her 80s was admitted with 5 days of progressive dyspnoea and hypoxic respiratory failure, in the setting of receiving a 3-week course of low-dose to moderate-dose prednisolone for a pruritic skin rash. Her medical history was not significant for major medical comorbidities or any other clear risk factors for secondary immunosuppression apart from advanced age. CT revealed widespread small-airway and parenchymal disease with ground-glass opacities consistent with atypical respiratory infection. Sputum PCR confirmed Pneumocystis jirovecii She was diagnosed with Pneumocystis jirovecii pneumonia (PJP) in the context of her clinical presentation, radiological features and PCR result. Her HIV status was negative. The patient was treated with 4 weeks of trimethoprim-sulfamethoxazole and 3 weeks of adjunctive prednisolone. She initially required high-dependency unit support with non-invasive ventilation. In this case report, we review the literature regarding PJP in the dermatology setting.
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Affiliation(s)
- Branko Borojevic
- General Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Esther Johns
- General Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Nihal Raju
- General Medicine, Austin Health, Heidelberg, Victoria, Australia
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Rúa-Figueroa Fernández de Larrinoa Í, Carreira PE, Brito García N, Díaz Del Campo Fontecha P, Pego Reigosa JM, Gómez Puerta JA, Ortega-Castro R, Tejera Segura B, Aguado García JM, Torre-Cisneros J, Valencia-Martín JL, Pereda CA, Nishishinya-Aquino MB, Otón Sánchez MT, Silva Fernández L, Maese Manzano J, Chamizo Carmona E, Correyero Plaza M. Recommendations for prevention of infection in systemic autoimmune rheumatic diseases. REUMATOLOGIA CLINICA 2022; 18:317-330. [PMID: 34607782 DOI: 10.1016/j.reumae.2021.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/11/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To develop recommendations for the prevention of infection in adult patients with systemic autoimmune rheumatic diseases (SARD). METHODS Clinical research questions relevant to the objective of the document were identified by a panel of experts selected based on their experience in the field. Systematic reviews of the available evidence were conducted, and evidence was graded according to the Scottish Intercollegiate Guidelines Network criteria. Specific recommendations were made. RESULTS Five questions were selected, referring to prevention of infection by Pneumocystis jirovecii with trimethoprim/sulfamethoxazole, primary and secondary prophylactic measures against hepatitis B virus, vaccination against human papillomavirus, vaccination against Streptococcus pneumoniae and vaccination against influenza virus, making a total of 18 recommendations, structured by question, based on the evidence found for the different SARD and/or expert consensus. CONCLUSIONS There is enough evidence on the safety and efficacy of vaccinations and other prophylactic measures against the microorganisms reviewed in this document to specifically recommend them for patients with SARD.
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Affiliation(s)
| | - Patricia E Carreira
- Servicio de Reumatología, Hospital Universitario 12 de octubre, Madrid, Spain
| | - Noé Brito García
- Unidad de Investigación, Sociedad Española de Reumatología, Madrid, Spain.
| | | | - José María Pego Reigosa
- Servicio de Reumatología, Complexo Hospitalario Universitario de Vigo, Grupo IRIDIS-VIGO (Investigation in Rheumatology and Immune-Mediated Diseases), Instituto de Investigación Sanitaria Galicia Sur (IISGS), Vigo, Spain
| | | | - Rafaela Ortega-Castro
- Unidad de Gestión Clínica de Reumatologia, Hospital Universitario Reina Sofía, Universidad de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
| | | | - José María Aguado García
- Unidad de Enfermedades Infecciosas, Hospital Universitario 12 de Octubre. Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Universidad Complutense Madrid, Madrid, Spain
| | - Julián Torre-Cisneros
- Servicio de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica (IMIBIC), Departamento de Ciencias Médicas y Quirúrgicas, Universidad de Córdoba, Córdoba, Spain
| | - José L Valencia-Martín
- Servicio de Medicina Preventiva y Salud Pública, Hospital Universitario Ramón y Cajal, Madrid, Spain
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