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Sauvat L, Denis L, Nourrisson C, Poirier P, Ruivard M, Le Guenno G. Pneumocystis jirovecii pneumonia in non-HIV patients: need for a more extended prophylaxis. Front Med (Lausanne) 2024; 11:1414092. [PMID: 38988362 PMCID: PMC11233525 DOI: 10.3389/fmed.2024.1414092] [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: 04/08/2024] [Accepted: 06/14/2024] [Indexed: 07/12/2024] Open
Abstract
Background Pneumocystis jirovecii pneumonia (PCP) has a significant mortality rate for non-HIV immunocompromised patients. Prevention is primarily based on combined trimethoprim and sulfamethoxazole (TMP-SMX) but guidelines on pneumocystosis prophylaxis are scattered and not consensual. Objectives This study aims to describe PCP in non-HIV patients and to review case by case the prior indication of prophylaxis according to specific guidelines.We included patients with confirmed diagnosis of PCP admitted to one university hospital from 2007 to 2020. Prior indication for pneumocystis prophylaxis was assessed according to the specific guidelines for the underlying pathology or treatment. Results Of 150 patients with a medical diagnosis of PCP, 78 were included. Four groups of underlying pathologies were identified: hematological pathologies (42%), autoimmune diseases (27%), organ transplantation (17%), and other pathologies at risk of PCP (14%). A small subgroup of 14 patients (18%) had received a prior prescription of pneumocystis prophylaxis but none at the time of the episode. Transfer to intensive care was necessary for 33 (42%) patients, and the mortality rate at 3 months was 20%. According to international disease society guidelines, 52 patients (59%) should have been on prophylaxis at the time of the pneumocystis episode. Lowest compliance with guidelines was observed in the hematological disease group for 24 patients (72%) without prescription of indicated prophylaxis. Conclusion Infectious disease specialists should draw up specific prophylactic guidelines against pneumocystis to promote a better prevention of the disease and include additional criteria in their recommendations according to individual characteristics to prevent fatal cases.
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Affiliation(s)
- Léo Sauvat
- Infection Control Department, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Laure Denis
- Department of Internal Medicine, CH Alpes - Lemans, Contamine sur Arve, France
| | - Céline Nourrisson
- Laboratory of Mycology and Parasitology, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 3IHP, Clermont-Ferrand, France
| | - Philippe Poirier
- Laboratory of Mycology and Parasitology, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 3IHP, Clermont-Ferrand, France
| | - Marc Ruivard
- Department of Internal Medicine, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Clermont-Ferrand, France
| | - Guillaume Le Guenno
- Department of Internal Medicine, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Clermont-Ferrand, France
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2
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Pena C, Costi AC, García L, García M. Severe infections in systemic necrotizing vasculitis. REUMATOLOGIA CLINICA 2024; 20:237-242. [PMID: 38821740 DOI: 10.1016/j.reumae.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/18/2024] [Indexed: 06/02/2024]
Abstract
Infections in patients with systemic vasculitis represent one of the main causes of mortality. Corticosteroid use, immunosuppressive therapy, age, associated organic involvement and dialysis dependence are risk factors of infection. OBJECTIVES To determine the prevalence of severe infection and associated factors in patients diagnosed with ANCA-associated vasculitis (AAV) and Polyarteritis Nodosa (PAN). METHODS retrospective study was conduced in a single rheumatology center (2000-2018). We included patients diagnosed with AAV (Granulomatosis with Polyangiitis (GPA), Eosinophilic Granulomatosis with Polyangiitis (EGPA) and Microscopic Polyangiitis (PAM) and Polyarteritis nodosa (PAN). Serious infectious events requiring hospitalisation or prolonged antibiotic/antiviral treatment, recurrent infection of Herpes Zoster Virus or opportunistic infections were evaluated. Sites of infection, isolated microorganisms and mortality related were analyzed. RESULTS 105 patients were analyzed, follow-up time median 18 m, 58.7% were women and median age was 52 years. Types of vasculitis: 41.9% PAM, 16.2% EPGA, 40% GPA, 1.9% PAN. Constitutional, pulmonary, renal and otorhinolaryngology manifestations were the most frequent. PREVALENCE OF INFECTION 34.2%, with a median of 3 months from diagnosis of vasculitis to the infectious event. Low respiratory tract (42.8%), sepsis (31.4%), and urinary tract (14.3%) were the most common sites of infections. Bacterial aetiology was the most prevalent (67.7%). Mortality at the first event was 14.3% and a 72.2% of patients were in the induction phase of treatment. Infectious events were significantly associated with age > 65 years (p = 0.030), presence of lung (p = 0.016) and renal involvement (p = 0.001), BVASv3 > 15, mortality (p = 0.0002). CONCLUSIONS The prevalence of infection was 34.2%. Lower airway infections, septicemia and urinary tract infections were the most prevalent. Infections were associated with renal and pulmonary involvement, age older than 65 years and score BVAS > 15. Severe infections were associated with mortality, especially in elderly patients.
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Affiliation(s)
- Claudia Pena
- Hospital Interzonal General de Agudos General José de San Martín, La Plata, Buenos Aires, Argentina.
| | - Ana Carolina Costi
- Hospital Interzonal General de Agudos General José de San Martín, La Plata, Buenos Aires, Argentina
| | - Lucila García
- Hospital Interzonal General de Agudos General José de San Martín, La Plata, Buenos Aires, Argentina
| | - Mercedes García
- Hospital Interzonal General de Agudos General José de San Martín, La Plata, Buenos Aires, Argentina
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3
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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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Matsumoto K, Suzuki K, Yasuoka H, Hirahashi J, Yoshida H, Magi M, Noguchi-Sasaki M, Kaneko Y, Takeuchi T. Longitudinal monitoring of circulating immune cell phenotypes in anti-neutrophil cytoplasmic antibody-associated vasculitis. Autoimmun Rev 2023; 22:103271. [PMID: 36627064 DOI: 10.1016/j.autrev.2023.103271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 01/05/2023] [Indexed: 01/09/2023]
Abstract
Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a necrotizing multiorgan autoimmune disease that affects small- to medium-sized blood vessels. Despite the improvements in treatments, half of the patients with AAV still experience disease relapses. In this review, we focus on peripheral leukocyte properties and phenotypes in patients with AAV. In particular, we explore longitudinal changes in circulating immune cell phenotypes during the active phase of the disease and treatment. The numbers and phenotypes of leukocytes in peripheral blood were differs between AAV and healthy controls, AAV in active versus inactive phase, AAV in treatment responders versus non-responders, and AAV with and without severe infection. Therefore, biomarkers detected in peripheral blood immune cells may be useful for longitudinal monitoring of disease activity in AAV.
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Affiliation(s)
- Kotaro Matsumoto
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan.
| | - Katsuya Suzuki
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hidekata Yasuoka
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan; Division of Rheumatology, Department of Internal Medicine, Fujita Health University School of Medicine, Aichi, Japan
| | - Junichi Hirahashi
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | | | - Mayu Magi
- Chugai Pharmaceutical Co. Ltd., Kanagawa, Japan
| | | | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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5
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Belov BS, Egorova ON, Tarasova GM, Muravieva NV. Infections and systemic vasculitis. MODERN RHEUMATOLOGY JOURNAL 2022. [DOI: 10.14412/1996-7012-2022-5-75-81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Infections and systemic vasculitis (SV) are characterized by mutual influence, which increases the risk of occurrence, aggravates the course and outcome of the disease. The review considers the issues related to both the trigger role of infections in the development of SV and comorbid infections (CI) that complicate the course of the disease. Recognition of the infectious etiology of SV is of great importance, since it requires a comprehensive examination and, if necessary, early and complete etiotropic treatment. Since SV per se and the use of both induction and maintenance immunosuppressive therapy are significant risk factors for secondary CIs, special attention should be paid to the prevention of the latter, including vaccination, primarily against influenza and pneumococcal infections.
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Affiliation(s)
- B. S. Belov
- V.A. Nasonova Research Institute of Rheumatology
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6
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Shams I, Ivory C, Cowan J. Duration of prednisone treatment before development of Pneumocystis jirovecii pneumonia in patients with vasculitis: A case series. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2022; 7:117-124. [PMID: 36337351 PMCID: PMC9608117 DOI: 10.3138/jammi-2021-0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/26/2021] [Accepted: 12/16/2021] [Indexed: 06/16/2023]
Abstract
BACKGROUND Optimal timing for Pneumocystis jirovecii pneumonia (PCP) prophylaxis among patients with vasculitis is not clear. We set out to characterize the clinical presentation and duration of prednisone use before the development of PCP among these patients. METHODS All patients with PCP at The Ottawa Hospital (TOH) between 2006 and 2017 were identified. Using TOH data repositories, the following data were extracted: prednisone dosage, treatment duration, other immunosuppressive medications, PCP prophylaxis, PCP treatment, and death. Data were reported as median and range or as mean and standard deviation. RESULTS We identified seven patients (5 men, 2 women) with biopsy-proven vasculitis who developed PCP: six with anti-neutrophil cytoplasmic antibody-associated vasculitis and one with giant cell arteritis. None of the patients were on PCP prophylaxis. The most common symptoms on presentation were cough and dyspnea. At diagnosis, the median lymphocyte count was 0.30 × 109/L (range 0.03-2.10), creatinine was 186 µmol/L (range 78-359), and lactate dehydrogenase was 471 U/L (range 301-1032). All patients were on prednisone at time of PCP diagnosis, with six on doses of ≥20 mg/day for at least 12 weeks. All but one patient were on additional immunosuppressants, with cyclophosphamide being the most common agent for five of the seven patients. Four (57%) required intensive care unit admission, and two (29%) died secondary to complications of PCP. CONCLUSIONS PCP is a severe and often fatal opportunistic infection among immunocompromised patients with vasculitis. Frequent evaluation of the need for prophylaxis is required for patients who remain on high-dose steroids and concomitant immunosuppressants.
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Affiliation(s)
- Ieta Shams
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Catherine Ivory
- Division of Rheumatology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Centre of Infection, Immunity and Inflammation, Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Juthaporn Cowan
- Centre of Infection, Immunity and Inflammation, Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Division of Infectious Diseases, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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7
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Gibelin A, Dumas G, Valade S, de Chambrun MP, Bagate F, Neuville M, Schneider F, Baboi L, Groh M, Raphalen JH, Chiche JD, De Prost N, Luyt CE, Guérin C, Maury E, de Montmollin E, Hertig A, Parrot A, Clere-Jehl R, Fartoukh M. Causes of acute respiratory failure in patients with small-vessel vasculitis admitted to intensive care units: a multicenter retrospective study. Ann Intensive Care 2021; 11:158. [PMID: 34817718 PMCID: PMC8613321 DOI: 10.1186/s13613-021-00946-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 11/02/2021] [Indexed: 12/11/2022] Open
Abstract
RATIONALE Acute respiratory failure (ARF) in patients admitted to the intensive care unit (ICU) with known or de novo small-vessel vasculitis (Svv) may be secondary to the underlying immune disease or to other causes. Early identification of the cause of ARF is essential to initiate the most appropriate treatment in a timely fashion. METHODS A retrospective multicenter study in 10 French ICUs from January 2007 to January 2018 to assess the clinical presentation, main causes and outcome of ARF associated with Svv, and to identify variables associated with non-immune etiology of ARF in patients with known Svv. RESULTS During the study period, 121 patients [62 (50-75) years; 62% male; median SAPSII and SOFA scores 39 (27-52) and 6 (4-8), respectively] were analyzed. An immune cause was identified in 67 (55%), and a non-immune cause in 54 (45%) patients. ARF was associated with several causes in 43% (n = 52) of cases. The main immune cause was diffuse alveolar hemorrhage (DAH) (n = 47, 39%), whereas the main non-immune cause was pulmonary infection (n = 35, 29%). The crude 90-day and 1-year mortality were higher in patients with non-immune ARF, as compared with their counterparts (32% and 38% vs. 15% and 20%, respectively; both p = 0.03), but was marginally significantly higher after adjusted analysis in a Cox model (p = 0.053). Among patients with a known Svv (n = 70), immunosuppression [OR 9.41 (1.52-58.3); p = 0.016], and a low vasculitis activity score [0.84 (0.77-0.93)] were independently associated with a non-immune cause, after adjustment for the time from disease onset to ARF, time from respiratory symptoms to ICU admission, and severe renal failure. CONCLUSIONS An extensive diagnosis workup is mandatory in ARF revealing or complicating Svv. Non-immune causes are involved in 43% of cases, and their short and mid-term prognosis may be poorer than those of immune ARF. Readily identified predictive factors of a non-immune cause could help avoiding unnecessary immunosuppressive therapies.
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Affiliation(s)
- Aude Gibelin
- Service de Médecine Intensive Réanimation, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Sorbonne Université, 4 rue de la chine, 75020, Paris, France.
| | - Guillaume Dumas
- Service de Médecine Intensive Réanimation, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Paris, France.,Service de Médecine Intensive Réanimation, Faculté de Médecine Sorbonne Université, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sandrine Valade
- Service de Médecine Intensive Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marc Pineton de Chambrun
- Service de Médecine Intensive Réanimation, Faculté de Médecine Sorbonne Université, Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - François Bagate
- Service de Médecine Intensive Réanimation, Faculté de Santé de Créteil, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP) and Groupe de Recherche Clinique CARMAS, Université Paris Est Créteil, Cedex 94010, Créteil, France
| | - Mathilde Neuville
- Service de Médecine Intensive et Réanimation Infectieuse, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, IAME, UMR 1137, Paris, France
| | - Francis Schneider
- Service de Médecine Intensive Réanimation, Hôpital Hautepierre, Strasbourg, France
| | - Loredana Baboi
- Service de Médecine Intensive-Réanimation Groupement Hospitalier Centre, Hôpital Edouard Herriot, Lyon, France
| | - Matthieu Groh
- Service de Médecine Interne, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jean-Herlé Raphalen
- Service de Réanimation Adultes, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jean-Daniel Chiche
- Service de Médecine Intensive Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Nicolas De Prost
- Service de Médecine Intensive Réanimation, Faculté de Santé de Créteil, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP) and Groupe de Recherche Clinique CARMAS, Université Paris Est Créteil, Cedex 94010, Créteil, France
| | - Charles-Edouard Luyt
- Service de Médecine Intensive Réanimation, Faculté de Médecine Sorbonne Université, Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Claude Guérin
- Service de Médecine Intensive-Réanimation Groupement Hospitalier Centre, Hôpital Edouard Herriot, Lyon, France
| | - Eric Maury
- Service de Médecine Intensive Réanimation, Faculté de Médecine Sorbonne Université, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Etienne de Montmollin
- Service de Médecine Intensive et Réanimation Infectieuse, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, IAME, UMR 1137, Paris, France
| | - Alexandre Hertig
- Service de Néphrologie, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Sorbonne Université, Paris, France
| | - Antoine Parrot
- Service de Médecine Intensive Réanimation, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Sorbonne Université, 4 rue de la chine, 75020, Paris, France
| | - Raphaël Clere-Jehl
- Service de Médecine Intensive Réanimation, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Muriel Fartoukh
- Service de Médecine Intensive Réanimation, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Sorbonne Université, 4 rue de la chine, 75020, Paris, France
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8
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Lécuyer R, Issa N, Tessoulin B, Lavergne RA, Morio F, Gabriel F, Canet E, Bressollette-Bodin C, Guillouzouic A, Boutoille D, Raffi F, Lecomte R, Le Turnier P, Deschanvres C, Camou F, Gaborit BJ. Epidemiology and clinical impact of respiratory co-infections at diagnosis of Pneumocystis jirovecii Pneumonia. J Infect Dis 2021; 225:868-880. [PMID: 34604908 DOI: 10.1093/infdis/jiab460] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 09/09/2021] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES To describe the epidemiology and clinical impact of respiratory co-infections at diagnosis of Pneumocystis jirovecii Pneumonia (PcP). METHODS A retrospective observational study was conducted between January 2011 and April 2019 to evaluate respiratory co-infections at diagnosis of PcP patients, in two tertiary care hospitals. Respiratory co-infection was defined by the identification of pathogens from P. jirovecii-positive samples. RESULTS Of the 7 882 respiratory samples tested for P. jirovecii during the 8-year study period, 328 patients with final diagnosis of PcP were included in this study. Mean age was 56.7 ± 14.9 years, 193 (58.8%) were male, 74 (22.6%) had a positive HIV serology, 125 (38.1%) had a viral co-infections, 76 (23.2%) a bacterial co-infections and 90-day mortality was 25.3%. In overall population, 90-Day mortality was independently associated with a solid tumor underlying disease (OR 11.8, 1.90-78, p=0.008), SOFA score at admission (OR 1.62, 1.34-2.05; p<0.001) and CMV respiratory co-infection (OR 3.44, 1.24-2.90; p=0.02). Among HIV-negative patients, respiratory CMV co-infection was associated with a worse prognosis, especially when treated with adjunctive corticosteroid therapy. CONCLUSIONS Respiratory CMV co-infection at diagnosis of PcP was independently associated with increased 90-day mortality, specifically in HIV-negative patients.
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Affiliation(s)
- Romain Lécuyer
- Department of Infectious Diseases, University Hospital of Nantes and CIC 1413, INSERM, Nantes, France.,EA 1155, Laboratory of targets and drugs for infections and cancer, IRS2-Nantes Biotech, Nantes, France
| | - Nahema Issa
- Intensive Care and Infectious Disease Unit, Groupe Saint-André, University Hospital, Bordeaux, France
| | - Benoit Tessoulin
- INSERM, U1232, Université de Nantes, Service d'Hématologie, University Hospital, Nantes, France
| | - Rose-Anne Lavergne
- EA 1155, Laboratory of targets and drugs for infections and cancer, IRS2-Nantes Biotech, Nantes, France.,Laboratoire de Parasitologie-Mycologie, Institut de Biologie, University Hospital, Nantes, France
| | - Florent Morio
- EA 1155, Laboratory of targets and drugs for infections and cancer, IRS2-Nantes Biotech, Nantes, France.,Laboratoire de Parasitologie-Mycologie, Institut de Biologie, University Hospital, Nantes, France
| | - Frederic Gabriel
- Centre Hospitalier Universitaire de Bordeaux, Service de Parasitologie Mycologie, F-33000, Bordeaux, France
| | - Emmanuel Canet
- Medical Intensive Care, University Hospital, Nantes, France
| | | | | | - David Boutoille
- Department of Infectious Diseases, University Hospital of Nantes and CIC 1413, INSERM, Nantes, France.,EA 3826, Laboratory of clinical and experimental therapeutics of infections, IRS2-Nantes Biotech, Nantes, France
| | - François Raffi
- Department of Infectious Diseases, University Hospital of Nantes and CIC 1413, INSERM, Nantes, France
| | - Raphael Lecomte
- Department of Infectious Diseases, University Hospital of Nantes and CIC 1413, INSERM, Nantes, France
| | - Paul Le Turnier
- Department of Infectious Diseases, University Hospital of Nantes and CIC 1413, INSERM, Nantes, France
| | - Colin Deschanvres
- Department of Infectious Diseases, University Hospital of Nantes and CIC 1413, INSERM, Nantes, France
| | - Fabrice Camou
- Intensive Care and Infectious Disease Unit, Groupe Saint-André, University Hospital, Bordeaux, France
| | - Benjamin Jean Gaborit
- Department of Infectious Diseases, University Hospital of Nantes and CIC 1413, INSERM, Nantes, France.,EA 3826, Laboratory of clinical and experimental therapeutics of infections, IRS2-Nantes Biotech, Nantes, France
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9
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Oelzner P, Wolf G. Risikostratifizierung bei ANCA-assoziierten
Vaskulitiden. AKTUEL RHEUMATOL 2021. [DOI: 10.1055/a-1380-2984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ZusammenfassungANCA-assoziierte Vaskulitiden (AAV) sind nekrotisierende Vaskulitiden der
kleinen bis mittelgroßen Gefäße, welche die
Granulomatose mit Polyangiitis (GPA), die mikroskopische Polyangiitis (MPA)
und die Eosinophile Granulomatose mit Polyangiitis (EGPA) umfassen. AAV
gehen häufig mit Organfunktion-bedrohenden Manifestationen und einer
entsprechend erhöhten Mortalität einher. Für die
Planung von Diagnostik, Therapie und Langzeitbetreuung ist daher eine
Risikostratifizierung im Hinblick auf Mortalität, Entwicklung
schwerer Organinsuffizienzen, insbesondere einer terminalen
Niereninsuffizienz, mögliche Therapieresistenz, Rezidive,
Infektionen und Malignome erforderlich. Wichtige Risikofaktoren für
erhöhte Mortalität und/oder terminale
Niereninsuffizienz sind neben der renalen Beteiligung per se eine bereits
zum Zeitpunkt der Diagnose deutlich eingeschränkte renale Funktion
einschliesslich initialer Dialysepflichtigkeit, eine hohe initiale
Aktivität der AAV gemessen am Birmingham Vaskulitis Activity Score,
aber auch kardiale und gastrointestinale Manifestationen, Infektionen,
Anämie sowie ein Alter von>65 Jahren. Histologisch ist der
Nachweis chronischer irreversibler glomerulärer und
tubulärer Läsionen in der Nierenbiopsie mit einer schlechten
Prognose im Hinblick auf die Nierenfunktion assoziiert. Basierend auf der
histopathologischen Klassifikation der ANCA-assoziierten Glomerulonephritis
(GN) ist der Befund einer sklerosierenden GN mit einer besonders
ungünstigen Prognose assoziiert, während die fokale GN sehr
selten zur terminalen Niereninsuffizienz führt. MPO-ANCA zeigen eine
Assoziation mit chronischen Läsionen in der Nierenbiopsie sowie
erhöhter Mortalität und erhöhtem Risiko für
terminale Niereninsuffizienz. Im Hinblick auf die pulmonale Beteiligung sind
alveoläre Hämorrhagie und interstitielle Lungenerkrankung
mit einer erhöhten Mortalität assoziiert. Bei EGPA wird die
Prognose entscheidend durch die Kardiomyopathie bestimmt. Risikofaktoren
für Rezidive weichen erheblich von denen für
Mortalität und terminale Niereninsuffizienz ab. Ein erhöhtes
Rezidivrisiko besteht bei Nachweis von PR3-ANCA, GPA und pulmonaler
Beteiligung. Auch bei granulomatösen Läsionen, Beteiligung
des oberen Respirationstraktes und kardiovaskulären Manifestationen
wird ein erhöhtes Rezidivrisiko beschrieben. Im Gegensatz zur
Assoziation einer initial schlechten Nierenfunktion mit Mortalität
und terminaler Niereninsuffizienz, wurde für Patienten mit initial
guter Nierenfunktion ein erhöhtes Rezidivrisiko gezeigt. Weitere
Risikofaktoren für Rezidive sind Staphylokokken-Besiedelung der
Nase, frühere Rezidive und ANCA-Positivität nach
Remissionsinduktion. Titeranstieg oder Wiederauftreten von ANCA zeigen nur
eine moderate Beziehung zum Rezidivrisiko. Der prädiktive Wert
für Rezidive ist offenbar bei bestimmten Subgruppen, wie bei
Patienten mit renaler Beteiligung und pulmonaler Hämorrhagie sowie
bei mit Rituximab-behandelten Patienten besser als bei Patienten mit
granulomatösen Manifestationen. Daher ist eine Therapieentscheidung
allein auf Basis der Entwicklung der ANCA-Titer nicht möglich.
Risikofaktoren für schwere Infektionen sind höher dosierte
und prolongierte Glukokortikoidtherapie, Leuko- und Lymphopenie,
höheres Lebenalter, Niereninsuffizienz und pulmonale Beteiligung.
Die Malignomrate insbesondere für Nicht-Melanom-Hauttumoren,
Harnblasenkarzinome und Leukämie ist bei AAV erhöht und
zeigt eine Assoziation mit hohen kumulativen Cyclophosphamiddosen. Da
insbesondere frühzeitige irreversible Organschäden die
Prognose bestimmen und Rezidive die Entwicklung irreversibler
Schäden treiben, sind frühestmögliche Diagnose und
Therapie sowie rasches Erkennen und Vermeiden von Rezidiven essentiell
für die Risikominimierung.
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Affiliation(s)
- Peter Oelzner
- Rheumatologie/Osteologie, Klinik für Innere Medizin
III, Universitätsklinikum Jena, Jena, Deutschland
| | - Gunter Wolf
- Nephrologie, Klinik für Innere Medizin III,
Universitätsklinikum Jena, Jena, Deutschland
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10
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Ghembaza A, Pourcher V, Saadoun D. Response. Chest 2020; 158:2705-2706. [DOI: 10.1016/j.chest.2020.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/10/2020] [Indexed: 11/24/2022] Open
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11
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Ghembaza A, Vautier M, Cacoub P, Pourcher V, Saadoun D. Risk Factors and Prevention of Pneumocystis jirovecii Pneumonia in Patients With Autoimmune and Inflammatory Diseases. Chest 2020; 158:2323-2332. [PMID: 32502592 DOI: 10.1016/j.chest.2020.05.558] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 05/21/2020] [Accepted: 05/28/2020] [Indexed: 02/02/2023] Open
Abstract
Patients with autoimmune and/or inflammatory diseases (AIIDs) are prone to serious infectious complications such as Pneumocystis jirovecii pneumonia (PJP). In non-HIV patients, the prognosis is poorer, and diagnostic tests are of lower sensitivity. Given the low incidence of PJP in AIIDs, with the exception of granulomatosis with polyangiitis, and the non-negligible side effects of chemoprophylaxis, routine prescription of primary prophylaxis is still debated. Absolute peripheral lymphopenia, high doses of corticosteroids, combination with other immunosuppressive agents, and concomitant lung disease are strong predictors for the development of PJP and thus should warrant primary prophylaxis. Trimethoprim-sulfamethoxazole is considered first-line therapy and is the most extensively used drug for PJP prophylaxis. Nevertheless, it may expose patients to side effects. Effective alternative drugs such as atovaquone or aerosolized pentamidine could be used when trimethoprim-sulfamethoxazole is not tolerated or contraindicated. No standard guidelines are available to guide PJP prophylaxis in patients with AIIDs. This review covers the epidemiology, risk factors, and prevention of pneumocystis in the context of AIIDs.
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Affiliation(s)
- Amine Ghembaza
- Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; Centre national de références Maladies Autoimmunes systémiques rares et Centre national de références Maladies Autoinflammatoires et amylose inflammatoire; Immunology-Immunopathology-Immunotherapy (I3), Sorbonne Universités, UPMC Université Paris 6, INSERM, UMR S 959, Paris, France
| | - Mathieu Vautier
- Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; Centre national de références Maladies Autoimmunes systémiques rares et Centre national de références Maladies Autoinflammatoires et amylose inflammatoire; Immunology-Immunopathology-Immunotherapy (I3), Sorbonne Universités, UPMC Université Paris 6, INSERM, UMR S 959, Paris, France
| | - Patrice Cacoub
- Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; Centre national de références Maladies Autoimmunes systémiques rares et Centre national de références Maladies Autoinflammatoires et amylose inflammatoire; Immunology-Immunopathology-Immunotherapy (I3), Sorbonne Universités, UPMC Université Paris 6, INSERM, UMR S 959, Paris, France
| | - Valérie Pourcher
- Service des maladies infectieuses et tropicales, hôpital Pitié-Salpêtrière, AP-HP, Paris, France; INSERM UMR-S 1136, Pierre Louis Institute of Epidemiology and Public Health, Sorbonne Université, Paris, France
| | - David Saadoun
- Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; Centre national de références Maladies Autoimmunes systémiques rares et Centre national de références Maladies Autoinflammatoires et amylose inflammatoire; Immunology-Immunopathology-Immunotherapy (I3), Sorbonne Universités, UPMC Université Paris 6, INSERM, UMR S 959, Paris, France.
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12
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Vela Casasempere P, Ruiz Torregrosa P, García Sevila R. Pneumocystis jirovecii in immunocompromised patients with rheumatic diseases. ACTA ACUST UNITED AC 2020; 17:290-296. [PMID: 32466869 DOI: 10.1016/j.reuma.2020.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 12/30/2019] [Accepted: 02/28/2020] [Indexed: 12/14/2022]
Abstract
Infections, including opportunistic infections, are a major and frequent cause of morbidity and mortality in patients with systemic autoimmune and rheumatic diseases. Pneumocystis jirovecii pneumonia, classically considered to be typical of HIV patients, transplanted patients or patients treated with oncological chemotherapy, is appearing increasingly frequently in these patients. Therefore, rheumatologists should know its mechanism of production, clinical manifestations, treatment and prophylaxis, all of which are addressed in this review.
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Affiliation(s)
- Paloma Vela Casasempere
- Sección de Reumatología. Hospital General Universitario de Alicante. ISABIAL, Alicante, España; Universidad Miguel Hernández, Alicante, España.
| | | | - Raquel García Sevila
- Servicio de Neumología. Hospital General Universitario de Alicante, Alicante, España
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13
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Thery-Casari C, Euvrard R, Mainbourg S, Durupt S, Reynaud Q, Durieu I, Belot A, Lobbes H, Cabrera N, Lega JC. Severe infections in patients with anti-neutrophil cytoplasmic antibody-associated vasculitides receiving rituximab: A meta-analysis. Autoimmun Rev 2020; 19:102505. [PMID: 32173512 DOI: 10.1016/j.autrev.2020.102505] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 12/31/2019] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The efficacy of rituximab (RTX) for remission induction and maintenance in patients with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) is now established, but the safety, particularly concerning severe infection risk, is not well known. OBJECTIVE The purpose of this meta-analysis is to assess the prevalence and incidence of severe infections and the factors explaining heterogeneity in AAV patients treated with RTX. METHODS PubMed and Embase were searched up to December 2017. Prevalence and incidence was pooled using a random-effects model in case of significant heterogeneity (I2 > 50%). Severe infection was defined as severe when it led to hospitalization, intravenous antibiotics therapy, and/or death. The heterogeneity was explored by subgroup analyses and meta-regression. RESULTS The included studies encompassed 1434 patients with a median age of 51.9 years. The overall prevalence and incidence of severe infections was 15.4% (95% CI [8.9; 23.3], I2 = 90%, 33 studies) and 6.5 per 100 person-years (PY) (95% CI [2.9; 11.4], I2 = 76%, 18 studies), respectively. The most common infections were bacterial (9.4%, 95% CI [5.1; 14.8]). The prevalence of opportunistic infection was 1.5% (95% CI [0.5; 3.1], I2 = 58%) including pneumocytis jirovecii infections (0.2%, 95% CI [0.0; 0.6], I2 = 0), irrespective of prophylaxis administration. Mortality related to infection was estimated at 0.7% (95% CI [0.2; 1.2], I2 = 27%). The RTX cumulative dose was positively associated with prevalence of infections (13 studies, prevalence increase of 4% per 100 mg, p < .0001). The incidence of infection was negatively associated with duration of follow-up (8 studies, incidence decrease of 9% per year, p = .03). CONCLUSION Prevalence and incidence of severe infections, mainly bacterial ones, were high in AAV patients treated with RTX. This meta-analysis highlights the need for prospective studies to stratify infectious risk and validate cumulative RTX dose and duration of follow-up as modifying factors.
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Affiliation(s)
- Clémence Thery-Casari
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Faculty of Medicine, Université de Lyon, Université Lyon 1, France; Lyon Immunopathology Federation (LIFE), University of Lyon, Hospices Civils de Lyon, France
| | - Romain Euvrard
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Faculty of Medicine, Université de Lyon, Université Lyon 1, France; Lyon Immunopathology Federation (LIFE), University of Lyon, Hospices Civils de Lyon, France
| | - Sabine Mainbourg
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Faculty of Medicine, Université de Lyon, Université Lyon 1, France; Lyon Immunopathology Federation (LIFE), University of Lyon, Hospices Civils de Lyon, France; Université de Lyon, Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Evolutive UMR 5558, F-69622 Villeurbanne, France
| | - Stéphane Durupt
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Lyon Immunopathology Federation (LIFE), University of Lyon, Hospices Civils de Lyon, France
| | - Quitterie Reynaud
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Faculty of Medicine, Université de Lyon, Université Lyon 1, France; Lyon Immunopathology Federation (LIFE), University of Lyon, Hospices Civils de Lyon, France; Univ Lyon, Health Services and Performance Research EA7425, Claude Bernard University Lyon, F-69003, France
| | - Isabelle Durieu
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Faculty of Medicine, Université de Lyon, Université Lyon 1, France; Lyon Immunopathology Federation (LIFE), University of Lyon, Hospices Civils de Lyon, France; Univ Lyon, Health Services and Performance Research EA7425, Claude Bernard University Lyon, F-69003, France
| | - Alexandre Belot
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Faculty of Medicine, Université de Lyon, Université Lyon 1, France; INSERM U1111, National Referral Centre for rare Juvenile Rheumatological and Autoimmune Diseases (RAISE) and Department of Paediatric Rheumatology, Lyon University Hospital, University of Lyon, France
| | - Hervé Lobbes
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Internal Medicine Department, University Hospital Clermont-Ferrand, 1 place Lucie et Raymond Aubrac, 63003 Clermont-Ferrand, France
| | - Natalia Cabrera
- Faculty of Medicine, Université de Lyon, Université Lyon 1, France; Lyon Immunopathology Federation (LIFE), University of Lyon, Hospices Civils de Lyon, France; Université de Lyon, Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Evolutive UMR 5558, F-69622 Villeurbanne, France
| | - Jean-Christophe Lega
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Faculty of Medicine, Université de Lyon, Université Lyon 1, France; Lyon Immunopathology Federation (LIFE), University of Lyon, Hospices Civils de Lyon, France; Université de Lyon, Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Evolutive UMR 5558, F-69622 Villeurbanne, France.
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14
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Choi CB, Park YB, Lee SW. Antineutrophil Cytoplasmic Antibody-Associated Vasculitis in Korea: A Narrative Review. Yonsei Med J 2019; 60:10-21. [PMID: 30554486 PMCID: PMC6298898 DOI: 10.3349/ymj.2019.60.1.10] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Indexed: 12/15/2022] Open
Abstract
Antineutrophil cytoplasmic antibody-associated vasculitis (AAV) is a group of systemic necrotising vasculitides, which often involve small vessels, and which lead to few or no immune deposits in affected organs. According to clinical manifestations and pathological features, AAV is classified into three variants: microscopic polyangiitis, granulomatosis with polyangiitis (GPA), and eosinophilic GPA. The American College of Rheumatology 1990 criteria contributed to the classification of AAV, although currently the algorithm suggested by the European Medicines Agency in 2007 and the Chapel Hill Consensus Conference Nomenclature of Vasculitides proposed in 2012 have encouraged physicians to classify AAV patients properly. So far, there have been noticeable advancements in studies on the pathophysiology of AAV and the classification criteria for AAV in Western countries. However, studies analysing clinical features of Korean patients with AAV have only been conducted and reported since 2000. One year-, 5 year-, and 10 year-cumulative patient survival rates are reported as 96.1, 94.8, and 92.8%. Furthermore, initial vasculitis activity, prognostic factor score, age and specific organ-involvement have been found to be associated with either all-cause mortality or poor disease course. The rate of serious infection is 28.6%, and 1 year-, 5 year- and 10 year-cumulative hospitalised infection free survival rates range from 85.1% to 72.7%. The overall standardised incidence ratio of cancer in AAV patients was deemed 1.43 compared to the general Korean population.
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Affiliation(s)
- Chan Bum Choi
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Yong Beom Park
- Division of Rheumatology, Department of Internal Medicine, and Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Won Lee
- Division of Rheumatology, Department of Internal Medicine, and Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Korea.
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15
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Late-onset Pneumocystis jirovecii pneumonia (PJP) in patients with ANCA-associated vasculitis. Clin Rheumatol 2018; 37:1991-1996. [DOI: 10.1007/s10067-018-4155-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 05/07/2018] [Accepted: 05/17/2018] [Indexed: 10/14/2022]
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16
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Pneumocystis Pneumonia and the Rheumatologist: Which Patients Are At Risk and How Can PCP Be Prevented? Curr Rheumatol Rep 2018; 19:35. [PMID: 28488228 DOI: 10.1007/s11926-017-0664-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Immunosuppressive therapy for connective tissue diseases (CTDs) is steadily becoming more intense. The resultant impairment in cell-mediated immunity has been accompanied by an increasing risk for opportunistic infection (OI). Pneumocystis pneumonia (PCP) has been recognized as an OI in patients with CTDs, but specific risk factors and precise indications for PCP prophylaxis remain poorly defined. This review was undertaken to update information on the risk of PCP in patients with CTDs and to examine current guidelines for PCP prophylaxis in this population. RECENT FINDINGS Data on the occurrence of PCP and indications for prophylaxis in patients with CTDs is sparse. Large systematic reviews did not incorporate patients with CTD secondary to the lack of randomized control trials. Upon reviewing guidelines published since 2015, prophylaxis for PCP is recommended only for patients with ANCA-positive vasculitis, specifically granulomatosis with polyangiitis (GPA), who are undergoing intense induction therapy. Evidence-based recommendations for the prophylaxis of PCP in patients with CTDs cannot be provided. There is expert consensus that PCP prophylaxis is warranted in patients with GPA undergoing induction therapy. Prophylaxis should perhaps also be considered for other CTD patients who are receiving similar intense immunosuppressive therapy especially if they are lymphopenic or have a low CD4 count.
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17
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Yoo J, Jung SM, Song JJ, Park YB, Lee SW. Birmingham vasculitis activity and chest manifestation at diagnosis can predict hospitalised infection in ANCA-associated vasculitis. Clin Rheumatol 2018; 37:2133-2141. [PMID: 29557539 DOI: 10.1007/s10067-018-4067-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 02/20/2018] [Accepted: 03/11/2018] [Indexed: 01/18/2023]
Abstract
We investigated the development rate and time, risk factors, predictors, and aetiologies of hospitalised infection in Korean patients with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). We retrospectively reviewed the medical records of 154 patients with AAV. Hospitalised infection was considered only when patients were admitted for serious infection related to AAV or AAV treatment. The gap-time was defined as the period from diagnosis to the first hospitalised infection or to the last visit for uninfected patients. We calculated Birmingham vasculitis activity score (BVAS) or BVAS for granulomatosis with polyangiitis (GPA) and five factor score (FFS (2009)) and reviewed medications administered. We set the optimal cut-offs of BVAS and that of FFS (2009) at diagnosis at 20.5 and 1.5. Forty-four patients (28.6%) were admitted for serious infection. One-, 5- and 10-year hospitalised infection free survival rates were 85.1, 77.9 and 72.7%, respectively. In multivariable logistic regression analysis of significant variables in comparison analysis, only chest manifestation at diagnosis (OR 2.692) was remarkably associated with hospitalised infection. In multivariable Cox hazard model analysis of significant variables in Kaplan-Meier analysis, BVAS at diagnosis ≥ 20.5 (HR 2.375) and chest manifestation at diagnosis (HR 2.422) were independent predictors of hospitalised infection during the gap-time. Bacterial pneumonia was the most common infectious aetiology (N = 29), followed by fungal infection including aspergillosis (N = 6). BVAS and chest manifestation at diagnosis can predict hospitalised infection during the gap-time.
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Affiliation(s)
- Juyoung Yoo
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Seung Min Jung
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Jason Jungsik Song
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.,Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang-Won Lee
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea. .,Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea.
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18
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Xue Y, Jiang L, Wan WG, Chen YM, Zhang J, Zhang ZC. Cytomegalovirus Pneumonia in Patients with Rheumatic Diseases After Immunosuppressive Therapy: A Single Center Study in China. Chin Med J (Engl) 2017; 129:267-73. [PMID: 26831226 PMCID: PMC4799568 DOI: 10.4103/0366-6999.174490] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Rheumatic diseases involve multiple organs that are affected by immunological mechanisms. Treatment with corticosteroids and immunosuppressive agents may also increase the frequency of infection. Cytomegalovirus (CMV) is a widespread herpes virus and a well-recognized pathogen, which causes an opportunistic and potentially fatal infection in immunocompromised patients. This retrospective study aimed to investigate the clinical and laboratory characteristics of CMV pneumonia in patients with rheumatic diseases after immunosuppressive therapy in a single center in Shanghai, China. Methods: Eight hundred and thirty-four patients with rheumatic diseases who had undergone CMV-DNA viral load tests were included, and the medical records of 142 patients who were positive for CMV-DNA in plasma samples were evaluated. GraphPad Prism version 5.013 (San Diego, CA, USA) was used to conduct statistical analysis. The correlation between CMV-DNA viral loads and lymphocyte counts was assessed using the Spearman rank correlation coefficient test. Significance between qualitative data was analyzed using Pearson's Chi-squared test. The cut-off thresholds for CMV-DNA viral load and lymphocyte count were determined by receiver operating characteristic (ROC) curve analysis. Results: One hundred and forty-two patients had positive CMV viral load tests. Of these 142 patients, 73 patients with CMV pneumonia were regarded as symptomatic, and the other 69 were asymptomatic. The symptomatic group received higher doses of prednisolone (PSL) and more frequently immunosuppressants than the asymptomatic group (P < 0.01). The symptomatic group had lower lymphocyte counts, especially CD4+ T-cells, than the asymptomatic group (P < 0.01). By ROC curve analysis, when CD4+ T-cell count was <0.39 × 109/L, patients with rheumatic diseases were at high risk for symptomatic CMV infection. The CMV-DNA load was significantly higher in the symptomatic patients than that in asymptomatic patients (P < 0.01; threshold viral loads: 1.75 × 104 copies/ml). Seven patients had a fatal outcome, and they had lower peripheral lymphocyte counts (P < 0.01), including CD4+ and CD8+ T-cells (P < 0.01). Conclusions: When CD4+ T-cell count is <0.39 × 109/L, patients are at high risk for pulmonary CMV infection. Patients are prone to be symptomatic with CMV-DNA load >1.75 × 104 copies/ml. Lymphopenia (especially CD4+ T-cells), presence of symptoms, and other infections, especially fungal infection, are significant risk factors for poor outcome, and a higher PSL dosage combined with immunosuppressants may predict CMV pneumonia.
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Affiliation(s)
| | | | | | | | | | - Zhen-Chun Zhang
- Institute of Rheumatology, Immunology and Allergy, Fudan University, Shanghai 200040; Department of Rheumatology, Linyi People's Hospital, Linyi, Shandong 276000, China
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Abstract
Corticosteroids are frequently used to treat rheumatic diseases. Their use comes with several well-established risks, including osteoporosis, avascular necrosis, glaucoma, and diabetes. The risk of infection is of utmost concern and is well documented, although randomized controlled trials of short-term and lower-dose steroids have generally shown little or no increased risk. Observational studies from the real world, however, have consistently shown dose-dependent increases in risk for serious infections as well as certain opportunistic infections. In patients who begin chronic steroid therapy, vaccination and screening strategies should be used in an attempt to mitigate this risk.
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Affiliation(s)
- Jameel Youssef
- Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA.
| | - Shannon A Novosad
- Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
| | - Kevin L Winthrop
- Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
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McGeoch L, Twilt M, Famorca L, Bakowsky V, Barra L, Benseler SM, Cabral DA, Carette S, Cox GP, Dhindsa N, Dipchand CS, Fifi-Mah A, Goulet M, Khalidi N, Khraishi MM, Liang P, Milman N, Pineau CA, Reich HN, Samadi N, Shojania K, Taylor-Gjevre R, Towheed TE, Trudeau J, Walsh M, Yacyshyn E, Pagnoux C. CanVasc Recommendations for the Management of Antineutrophil Cytoplasm Antibody-associated Vasculitides. J Rheumatol 2015; 43:97-120. [DOI: 10.3899/jrheum.150376] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2015] [Indexed: 01/14/2023]
Abstract
Objective.The Canadian Vasculitis research network (CanVasc) is composed of physicians from different medical specialties and researchers with expertise in vasculitis. One of its aims is to develop recommendations for the diagnosis and management of antineutrophil cytoplasm antibody (ANCA)-associated vasculitides (AAV) in Canada.Methods.Diagnostic and therapeutic questions were developed based on the results of a national needs assessment survey. A systematic review of existing non-Canadian recommendations and guidelines for the diagnosis and management of AAV and studies of AAV published after the 2009 European League Against Rheumatism/European Vasculitis Society recommendations (publication date: January 2009) until November 2014 was performed in the Medline database, Cochrane library, and main vasculitis conference proceedings. Quality of supporting evidence for each therapeutic recommendation was graded. The full working group as well as additional reviewers, including patients, reviewed the developed therapeutic recommendations and nontherapeutic statements using a modified 2-step Delphi technique and through discussion to reach consensus.Results.Nineteen recommendations and 17 statements addressing general AAV diagnosis and management were developed, as well as appendices for practical use, for rheumatologists, nephrologists, respirologists, general internists, and all other healthcare professionals more occasionally involved in the management of patients with AAV in community and academic practice settings.Conclusion.These recommendations were developed based on a synthesis of existing international guidelines, other published supporting evidence, and expert consensus considering the Canadian healthcare context, with the intention of promoting best practices and improving healthcare delivery for patients with AAV.
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Papadopoulou D, Tsoulas C, Tragiannidis A, Sipsas NV. Role of vaccinations and prophylaxis in rheumatic diseases. Best Pract Res Clin Rheumatol 2015; 29:306-18. [PMID: 26362746 DOI: 10.1016/j.berh.2015.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 12/29/2014] [Accepted: 02/10/2015] [Indexed: 12/26/2022]
Abstract
Targeted strategies for reducing the increased risk of infection in patients with autoimmune rheumatic diseases include vaccinations as well as antibiotic prophylaxis in selected patients. However, there are still issues under debate: Is vaccination in patients with rheumatic diseases immunogenic? Is it safe? What is the impact of immunosuppressive drugs on vaccine immunogenicity and safety? Does vaccination cause disease flares? In which cases is prophylaxis against Pneumocystis jirovecii required? This review addresses these important questions to which clinicians and researchers still do not have definite answers. The first part includes immunization recommendations and reviews current data on vaccine efficacy and safety in patients with rheumatic diseases. The second part discusses prophylaxis for Pneumocystis pneumonia.
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Affiliation(s)
- Despoina Papadopoulou
- Pain and Palliative Care Unit, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Christos Tsoulas
- Institute for Continuing Medical Education of Ioannina, Ioannina, Greece.
| | - Athanassios Tragiannidis
- Hematology and Oncology Unit, Second Department of Pediatrics, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Nikolaos V Sipsas
- Infectious Disease Unit, Pathophysiology Department, Laikon General Hospital and Medical School, National and Kapodistrian University of Athens, Athens, Greece.
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Kronbichler A, Jayne DRW, Mayer G. Frequency, risk factors and prophylaxis of infection in ANCA-associated vasculitis. Eur J Clin Invest 2015; 45:346-68. [PMID: 25627555 DOI: 10.1111/eci.12410] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 01/21/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Antineutrophil cytoplasm antibody (ANCA)-associated vasculitides are potentially life-threatening disorders. MATERIALS AND METHODS Even though immunosuppressive therapy improves the prognosis, adverse events, either attributable to persistent disease activity or side effects of treatment remain a challenge. Infectious complications are the leading cause of death in the first year after diagnosis and a major cause of morbidity and mortality thereafter. RESULTS Their incidence in clinical trials varies considerably but opportunistic and life-threatening infections, such as Pneumocystis jirovecii pneumonia or systemic cytomegalovirus infections, are frequent and thus predisposing/risk factors need to be defined. Pneumocystis jirovecii pneumonia has been associated with a lymphocyte count below 300/mm(3) . Additionally, besides the aggressiveness of the immunosuppressive regimen administered (especially the cumulative dose of steroids and cyclophosphamide), an elevated serum creatinine or dialysis dependency, older age and pulmonary involvement increase the rate of infectious complications. CONCLUSIONS We suggest to routinely prescribe trimethoprim-sulfamethoxazole or antimicrobial agents such as pentamidine in case of intolerance or contraindication in the early phase of induction therapy irrespective of the immunosuppressive strategy used and to continue therapy, together with other targeted measures (antiviral, antimycotic or antibiotic) in the presence of risk factors for a prolonged period of time. Finally, there is an urgent need to standardize the reporting of infectious complications in clinical trials to enable comparing the adverse event spectrum of distinct treatment approaches more appropriately.
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Affiliation(s)
- Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University of Innsbruck, Innsbruck, Austria; Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK
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Ernst E, Girndt M, Pliquett RU. A case of granulomatosis with polyangiitis complicated by cyclophosphamide toxicity and opportunistic infections: choosing between Scylla and Charybdis. BMC Nephrol 2014; 15:28. [PMID: 24495297 PMCID: PMC3937139 DOI: 10.1186/1471-2369-15-28] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Accepted: 02/02/2014] [Indexed: 11/10/2022] Open
Abstract
Background We report a case of progressive Granulomatosis with Polyangiitis (Wegener’s Granulomatosis) with life-threatening complications of both the underlying disease and induction immunosuppressive therapy. Here, for the first time, cyclophosphamide toxicity and severe opportunistic infections including pneumocystis jirovecii- pneumonia were found in one case in a close temporal relationship. Case presentation A 34-year-old male patient of Caucasian ethnicity presented with acute renal failure necessitating hemodialysis treatment due to Granulomatosis with Polyangiitis (Wegener’s Granulomatosis). Kidney disease progressed to end-stage renal disease shortly after first diagnosis. After the 2nd bolus of cyclophosphamide shortly, induction immunosuppression (glucocorticoid/cyclophosphamide) was interrupted for repeat infections and resumed 5 years later. By that time, the lungs developed large pulmonary cavernae most likely due to smoldering granuloma indicative for the failed goal of disease remission. Therefore, induction immunosuppression was resumed. Following two monthly boli of cyclophosphamide, the patient developed pericardial effusion and, consecutively, atrioventricular blockade most likely due to cyclophosphamide. After recovery, the patient was discharged without cotrimoxacole. 10 weeks after the last cyclophosphamide bolus and 6 weeks after cessation of cotrimoxacole, the patient was readmitted to the intensive-care unit with Pneumocystis jirovecii pneumonia, and died 6 months later or 74 months after first diagnosis of Granulomatosis with Polyangiitis. Conclusions This case illustrates both the need for adequate immunosuppressive therapy to reach disease remission and the limitations thereof in terms of complications including cardiotoxicity of cyclophosphamide and Pneumocystis jirovecii pneumonia. In line with current recommendations, the present case strongly encourages pneumocystis jirovecii- pneumonia chemoprophylaxis for at least 6 months following induction therapy in Granulomatosis with Polyangiitis.
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Affiliation(s)
| | | | - Rainer U Pliquett
- Martin-Luther-University Halle-Wittenberg, Clinic of Internal Medicine 2, Department of Nephrology, Ernst-Grube-Str, 40, 06120 Halle (Saale), Germany.
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Roblot F. Management ofPneumocystispneumonia in patients with inflammatory disorders. Expert Rev Anti Infect Ther 2014; 3:435-44. [PMID: 15954859 DOI: 10.1586/14787210.3.3.435] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Pneumocystis jirovecii is an atypical fungus that causes Pneumocystis pneumonia in immunocompromised patients. Underlying diseases associated with Pneumocystis pneumonia mainly consist of hematologic malignancies, solid tumors, organ transplant recipients and inflammatory disorders. Currently, inflammatory disorders represent 20% of underlying diseases. Corticosteroids are considered as a major risk factor. Recently introduced immunosuppressive drugs, such as antitumor necrosis factor monoclonal antibodies, could enhance the risk of Pneumocystis pneumonia. In patients with inflammatory disorders, lymphopenia is probably a determining factor but CD4+ T-cell count associated with the risk of Pneumocystis pneumonia remains unassessed. The diagnosis is based upon clinical, radiologic and biologic data. The identification of P. jirovecii usually requires a lower respiratory tract specimen, even if oral washes samples seem to be promising. According to recent data, immunofluorescent stains should be considered as the new gold standard, and specialized techniques such as PCR should be applied for sputum samples or oral washes. Recommendations on prophylaxis remains controversial except in patients with Wegener's granulomatosis and systemic lupus erythematosus. Cotrimoxazole is the preferred agent for prophylaxis as well as for treatment. An adjunctive corticosteroid therapy is usually prescribed despite the lack of evidence for utility in patients with inflammatory disorders. As person-to-person transmission is the most likely mode of acquiring P. jirovecii, isolation precautions should be advised.
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Affiliation(s)
- F Roblot
- Department of Internal Medicine, University Hospital, Poitiers, France.
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Ogawa J, Harigai M, Nagasaka K, Nakamura T, Miyasaka N. Prediction of and prophylaxis againstPneumocystispneumonia in patients with connective tissue diseases undergoing medium- or high-dose corticosteroid therapy. Mod Rheumatol 2014. [DOI: 10.3109/pl00021707] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Guillevin L. Infections in vasculitis. Best Pract Res Clin Rheumatol 2013; 27:19-31. [PMID: 23507054 DOI: 10.1016/j.berh.2013.01.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 01/25/2013] [Indexed: 12/31/2022]
Abstract
Infections, mainly viral, are the cause of some vasculitides, like polyarteritis nodosa (hepatitis B virus) or mixed cryoglobulinemia (hepatitis C virus), and it has been hypothesized that others might be due to infectious agents (HIV, EBV, parvovirus...). Among etiologies of vasculitis, the responsibility of a Burkholderia-like strain has been recently demonstrated as the cause of giant-cell arteritis. On the other hand, patients frequently develop infections, mainly as a consequence of steroids, immunosuppressants and most immunomodulating treatments prescribed to treat vasculitides. Infections occur when patients receive steroids and immunosuppressants, especially in the long term. They are more frequently observed in elderly patients or in patients with poor general condition. Infection risk is not reduced when biotherapies are prescribed to induce or maintain remission. Patients, considered at higher risk for infections, should be followed closely and their immunological status monitored periodically. We recommend especially to monitor neutrophiles, lymphocytes and if needed CD3-, CD4- and CD8-cell counts in patients receiving steroids and cyclophosphamide or other cytotoxic agents. In patients treated with rituximab, CD19 and gammaglobulins should be monitored regularly. Prophylaxis are needed in patients at risk to develop infections.
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Affiliation(s)
- Loïc Guillevin
- Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, 27, rue du faubourg Saint-Jacques, 75679 Paris Cedex, France.
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Grossi O, Généreau T. Corticoïdes et… infections, dopage, chirurgie et sexualité. Rev Med Interne 2013; 34:269-78. [DOI: 10.1016/j.revmed.2012.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 12/12/2012] [Indexed: 12/22/2022]
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Comment traiter une vascularite nécrosante ? Presse Med 2012; 41:1024-30. [DOI: 10.1016/j.lpm.2012.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Revised: 06/16/2012] [Accepted: 06/22/2012] [Indexed: 11/19/2022] Open
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Tasaka S, Tokuda H. Pneumocystis jirovecii pneumonia in non-HIV-infected patients in the era of novel immunosuppressive therapies. J Infect Chemother 2012; 18:793-806. [PMID: 22864454 DOI: 10.1007/s10156-012-0453-0] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Indexed: 12/15/2022]
Abstract
In human immunodeficiency virus (HIV)-infected patients, Pneumocystis jirovecii pneumonia (PCP) is a well-known opportunistic infection, and its management has been established. However, PCP is an emerging threat to immunocompromised patients without HIV infection, such as those receiving novel immunosuppressive therapeutics for malignancy, organ transplantation, or connective tissue diseases. Clinical manifestations of PCP are quite different between patients with and without HIV infections. In patients without HIV infection, PCP rapidly progresses, is difficult to diagnose correctly, and causes severe respiratory failure with a poor prognosis. High-resolution computed tomography findings are different between PCP patients with HIV infection and those without. These differences in clinical and radiologic features are the result of severe or dysregulated inflammatory responses that are evoked by a relatively small number of Pneumocystis organisms in patients without HIV infection. In recent years, the usefulness of PCR and serum β-D-glucan assay for rapid and noninvasive diagnosis of PCP has been revealed. Although corticosteroid adjunctive to anti-Pneumocystis agents has been shown to be beneficial in some populations, the optimal dose and duration remain to be determined. Recent investigations revealed that Pneumocystis colonization is prevalent, and that asymptomatic carriers are at risk for developing PCP and can serve as the reservoir for the spread of Pneumocystis by person-to-person transmission. These findings suggest the need for chemoprophylaxis in immunocompromised patients without HIV infection, although its indication and duration are still controversial. Because a variety of novel immunosuppressive therapeutics have been emerging in medical practice, further innovations in the diagnosis and treatment of PCP are needed.
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Affiliation(s)
- Sadatomo Tasaka
- Division of Pulmonary Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
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Régent A, Kluger N, Bérezné A, Lassoued K, Mouthon L. [Lymphocytopenia: aetiology and diagnosis, when to think about idiopathic CD4(+) lymphocytopenia?]. Rev Med Interne 2012; 33:628-34. [PMID: 22658164 PMCID: PMC7115373 DOI: 10.1016/j.revmed.2012.04.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 04/24/2012] [Indexed: 11/16/2022]
Abstract
Une lymphopénie est définie par un nombre de lymphocytes circulants inférieur à 1500/mm3 chez l’adulte et 4500/mm3 chez l’enfant avant huit mois. La lymphopénie peut être globale ou sélective, affectant une population lymphocytaire particulière. Le diagnostic étiologique doit tenir compte de l’âge, du contexte, des manifestations clinicobiologiques associées et des thérapeutiques reçues. Les lymphopénies de l’adulte peuvent être liées schématiquement à : (1) une insuffisance de production (carence en zinc, corticothérapie, déficits immunitaires primitifs…), (2) un excès de catabolisme (radiothérapie, chimiothérapie, traitements immunosuppresseurs, infection par le VIH ou lupus systémique, etc.), (3) une modification de la répartition des lymphocytes (infections virales, choc septique, brûlures étendues, hypersplénisme, granulomatoses, etc.), (4) les étiologies multifactorielles ou non identifiées (insuffisance rénale chronique, certaines hémopathies lymphoïdes, tumeur solide, causes ethniques, etc.). Chez l’enfant, à ces étiologies s’ajoutent d’autres déficits immunitaires primitifs d’expression sévère (défaut des précurseurs thymiques, déficit cytokinique, défaut de synthèse des récepteurs des lymphocytes B et T et défaut de la transduction du signal ou des interactions cellulaires). La lymphopénie CD4+ idiopathique de l’adulte est un diagnostic d’élimination. Cette affection rare se définit par une lymphopénie T CD4+ inférieure ou égale à 300/mm3 ou inférieure ou égale à 20 % des lymphocytes totaux, persistante en l’absence de diagnostic alternatif. Elle peut être asymptomatique, s’associer à des infections à germes opportunistes, ou se compliquer de symptômes auto-immuns (en particulier cytopénies) ainsi que de néoplasies. Le traitement, calqué sur la prise en charge des patients infectés par le VIH, peut nécessiter le recours à une immunothérapie spécifique dont le bénéfice clinique reste à évaluer.
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Affiliation(s)
- A Régent
- Université Paris Descartes, 12, rue de l'École de médecine, 75270 Paris cedex 06, France
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Affiliation(s)
- Karna K. Sundsted
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Mayo Clinic, Rochester, MN
| | - Husnain Syed
- Fellow in Hospital Internal Medicine, Mayo School of Graduate Medical Education, Mayo Clinic, Rochester, MN
| | - M. Caroline Burton
- Adviser to resident and fellow and Consultant in Hospital Internal Medicine, Mayo Clinic, Rochester, MN
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Kermani TA, Ytterberg SR, Warrington KJ. Pneumocystis jiroveci pneumonia in giant cell arteritis: A case series. Arthritis Care Res (Hoboken) 2011; 63:761-5. [PMID: 21240966 DOI: 10.1002/acr.20435] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To describe the clinical presentation, laboratory findings, and outcome of patients with Pneumocystis jiroveci pneumonia (PCP) and biopsy-proven giant cell arteritis (GCA) seen at a tertiary referral center. METHODS Using International Classification of Diseases, Ninth Revision codes, all patients with GCA and PCP between January 1, 1976 and December 31, 2008 were identified. Medical records were reviewed. PCP was defined by the identification of Pneumocystis jiroveci organisms in the clinical setting of pneumonia. RESULTS We identified 7 patients with GCA (5 women and 2 men) who developed PCP (the mean ± SD age at diagnosis was 71.6 ± 6.1 years). The median time from GCA diagnosis to PCP diagnosis was 3 months (range 1-18 months). All patients were taking prednisone (the median dosage 50 mg/day [range 30-80]) when diagnosed as having PCP. No patients were receiving PCP prophylaxis. PCP was diagnosed by positive smear on bronchoalveolar lavage fluid in 6 patients (86%) and by positive sputum polymerase chain reaction in 1 patient. All the patients were hospitalized (median duration 17 days [range 12-39 days]). Four patients (57%) were admitted to the intensive care unit. Three patients (43%) required mechanical ventilation. Two patients (29%) died; both were on mechanical ventilation. CONCLUSION Although PCP is rare among patients with GCA, this preventable infection is associated with significant morbidity and mortality.
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Holle JU, Moosig F, Dalhoff K, Gross WL. Conditions in subjects with rheumatic diseases: pulmonary manifestations of vasculitides. Arthritis Res Ther 2011; 13:224. [PMID: 21722330 PMCID: PMC3218869 DOI: 10.1186/ar3307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Pulmonary involvement is a common complication of vasculitides, especially small vessel vasculitides. This review provides an overview of vasculitic manifestations of the lung as well as of other organs involved in vasculitides. Furthermore, it provides the diagnostic procedures required to asses a patient with vasculitic lung involvement and gives an overview of current treatment strategies.
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Affiliation(s)
- Julia U Holle
- Vasculitis Center, University Hospital Schleswig-Holstein, Campus Lübeck and Klinikum Bad Bramstedt, Germany
| | - Frank Moosig
- Vasculitis Center, University Hospital Schleswig-Holstein, Campus Lübeck and Klinikum Bad Bramstedt, Germany
| | - Klaus Dalhoff
- Department of Pulmology, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Wolfgang L Gross
- Vasculitis Center, University Hospital Schleswig-Holstein, Campus Lübeck and Klinikum Bad Bramstedt, Germany
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Carmona EM, Limper AH. Update on the diagnosis and treatment of Pneumocystis pneumonia. Ther Adv Respir Dis 2010; 5:41-59. [PMID: 20736243 DOI: 10.1177/1753465810380102] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Pneumocystis is an opportunistic fungal pathogen that causes an often-lethal pneumonia in immunocompromised hosts. Although the organism was discovered in the early 1900s, the first cases of Pneumocystis pneumonia in humans were initially recognized in Central Europe after the Second World War in premature and malnourished infants. This unusual lung infection was known as plasma cellular interstitial pneumonitis of the newborn, and was characterized by severe respiratory distress and cyanosis with little or no fever and no pathognomic physical signs. At that time, only anecdotal cases were reported in adults and usually these patients had a baseline malignancy that led to a malnourished state. In the 1960-1970s additional cases were described in adults and children with hematological malignancies, but Pneumocystis pneumonia was still considered a rare disease. However, in the 1980s, with the onset of the HIV epidemic, Pneumocystis prevalence increased dramatically and became widely recognized as an opportunistic infection that caused potentially life-treating pneumonia in patients with impaired immunity. During this time period, prophylaxis against this organism was more generally instituted in high-risk patients. In the 1990s, with widespread use of prophylaxis and the initiation of highly active antiretroviral therapy (HAART) in the treatment of HIV-infected patients, the number of cases in this specific population decreased. However, Pneumocystis pneumonia still remains an important cause of severe pneumonia in patients with HIV infection and is still considered a principal AIDS-defining illness. Despite the decreased number of cases among HIV-infected patients over the past decade, Pneumocystis pneumonia continues to be a serious problem in immunodeficient patients with other immunosuppressive conditions. This is mostly due to increased use of immunosuppressive medications to treat patients with autoimmune diseases, following bone marrow and solid organ transplantation, and in patients with hematological and solid malignancies. Patients with hematologic disorders and solid organ and hematopoietic stem cell transplantation are currently the most vulnerable groups at risk for developing this infection. However, any patient with an impaired immunity, such as those receiving moderate doses of oral steroids for greater than 4 weeks or those receiving other immunosuppressive medications are at also at significant risk.
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Affiliation(s)
- Eva M Carmona
- Thoracic Diseases Research Unit and the Division of Pulmonary and Critical Care and Internal Medicine, Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, MN 55905, USA
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Holle JU, Moosig F, Gross WL. Diagnostic and therapeutic management of Churg-Strauss syndrome. Expert Rev Clin Immunol 2010; 5:813-23. [PMID: 20477699 DOI: 10.1586/eci.09.41] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Churg-Strauss syndrome is a rare small-vessel vasculitis that is associated with asthma, granulomatous inflammation, peripheral/tissue eosinophilia and a positive antineutrophil cytoplasmic antibody status (in approximately 40% of patients). The disease can be organ- and life-threatening, either due to tissue eosinophil infiltration such as myocarditis or due to vasculitis manifestations, for example glomerulonephritis. Furthermore, life-threatening disease can also occur due to the side effects of immunosuppression, for example, infection. A thorough diagnostic work-up should be performed in order to identify all organs involved and to rule out other disorders with similar features, such as hypereosinophilic syndrome. Therapeutic management is conducted according to disease stage and activity. Glucocorticoids remain the mainstay of therapy; however, further immunosuppressants (e.g., cyclophosphamide for life-threatening disease) are usually required. Future promising therapy options target cytokines involved in the disease process, such as IL-5.
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Affiliation(s)
- Julia U Holle
- University Hospital Schleswig-Holstein, Campus Luebeck, Dept of Rheumatology and Klinikum Bad Bramstedt, Dept of Rheumatology and Immunology, Oskar-Alexander-Strasse 26, 24576 Bad, Bramstedt, Germany.
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de Souza FHC, Radu Halpern AS, Valente Barbas CS, Shinjo SK. Wegener's granulomatosis: experience from a Brazilian tertiary center. Clin Rheumatol 2010; 29:855-60. [PMID: 20195878 DOI: 10.1007/s10067-010-1408-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2009] [Revised: 02/05/2010] [Accepted: 02/12/2010] [Indexed: 10/19/2022]
Abstract
Most epidemiological studies with Wegener's granulomatosis (WG) patients are based on populations from the Northern hemisphere, whereas very few studies have been conducted in Southern hemisphere populations, particularly from South America. The authors performed a large retrospective, demographic study including clinical and laboratory profiles of 134 consecutive WG patients seen at one Brazilian center from 1999 to 2009. Mean age at initial WG diagnosis was 43.4 +/- 15.5 years, and mean disease duration was 8.6 +/- 6.6 years. Sixty-four (47.8%) patients were male and a total of 113 (84.3%) subjects were white. Ear/nose/throat involvement occurred in 85.8%. The classic lung and renal involvement were observed in 77.6% and 75.4%, respectively, followed by ocular (35.8%), musculoskeletal (33.4%), cutaneous (29.1%), neurological (20.1%), cardiac (11.2%), and genitourinary involvement in 2.2% of cases. Cytoplasmic pattern-antineutrophil cytoplasmic antibody was detected in 83 (61.9%) cases. Ten (7.5%) individuals presented limited forms of WG. Classic therapy with corticosteroids and cyclophosphamide was used in 97 cases (72.4%). There were no cases of tuberculosis or Pneumocystis jiroveci pneumonia, but cutaneous herpes zoster occurred in eight (6.0%) individuals. There were 29 deaths (21.6%). Eighteen patients died of septic shock (mainly bacterial pneumonia), whereas four died of alveolar hemorrhage, four of myocardial infarction, and three of other causes. In summary, our data from a very large retrospective and descriptive study mirrored the main clinical features of WG described in other countries, demonstrating that they may serve as a reference for South American populations.
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Affiliation(s)
- Fernando Henrique Carlos de Souza
- Division of Rheumatology, Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3 degrees andar, Sala 3190, CEP 01246-903 São Paulo, Brazil
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Cettomai D, Gelber AC, Christopher-Stine L. A survey of rheumatologists' practice for prescribing pneumocystis prophylaxis. J Rheumatol 2010; 37:792-9. [PMID: 20194450 DOI: 10.3899/jrheum.090843] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Pneumocystis pneumonia (PCP) occurs in immunocompromised hosts, in both the presence and absence of human immunodeficiency virus (HIV) infection, with substantial morbidity and a heightened mortality. We assessed practice patterns among rheumatologists for prescribing PCP prophylaxis. METHODS Invitations to an online international survey were e-mailed to 3150 consecutive members of the American College of Rheumatology. RESULTS Completed surveys were returned by 727 (23.1%) members. Among respondents, 505 (69.5%) reported prescribing prophylaxis. Factors associated with significantly higher frequency of prescribing PCP prophylaxis included female gender (OR 1.47, p = 0.03), US-based (OR 1.77, p = 0.004), academic-based (OR 2.75, p < 0.001), in practice less than 10 years (OR 4.08, p < 0.001), having previously treated PCP (OR 2.62, p < 0.001), and in a practice with a higher proportion of patients maintained on chronic glucocorticoids (OR 2.04, p < 0.001) or other immunosuppressant medications (OR 3.19, p = 0.003). In multivariate analysis, rheumatologists early in their careers and those with academic and US-based practices were more likely to prescribe prophylaxis. Among prescribers, the most important determinants for issuing prophylaxis were treatment regimen (68.6%), rheumatologic diagnosis (9.3%), and medication dosage (8.3%). CONCLUSION Nearly one-third (30%) of the rheumatologists surveyed reported that they never prescribed PCP prophylaxis. While the patient characteristics for which prophylaxis was prescribed varied widely, physician demographics were strongly predictive of PCP prophylaxis use. These findings suggest that development of consensus guidelines might influence clinical decision-making regarding PCP prophylaxis in HIV-negative patients with rheumatologic diagnoses.
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Affiliation(s)
- Deanna Cettomai
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21224, USA
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Catherinot E, Lanternier F, Bougnoux ME, Lecuit M, Couderc LJ, Lortholary O. Pneumocystis jirovecii Pneumonia. Infect Dis Clin North Am 2010; 24:107-38. [PMID: 20171548 DOI: 10.1016/j.idc.2009.10.010] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Pneumocystis jirovecii has gained attention during the last decade in the context of the AIDS epidemic and the increasing use of cytotoxic and immunosuppressive therapies. This article summarizes current knowledge on biology, pathophysiology, epidemiology, diagnosis, prevention, and treatment of pulmonary P jirovecii infection, with a particular focus on the evolving pathophysiology and epidemiology. Pneumocystis pneumonia still remains a severe opportunistic infection, associated with a high mortality rate.
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Affiliation(s)
- Emilie Catherinot
- Université Paris Descartes, Service de Maladies Infectieuses et Tropicales, 149 Rue de Sèvres, Centre d'Infectiologie Necker-Pasteur, Hôpital Necker-Enfants Malades, Paris 75015, France
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Facteurs favorisants de la pneumocystose (PPC) chez les malades immunodéprimés non infectés par le VIH. J Mycol Med 2009. [DOI: 10.1016/j.mycmed.2009.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Moosig F, Holle JU, Gross WL. Value of anti-infective chemoprophylaxis in primary systemic vasculitis: what is the evidence? Arthritis Res Ther 2009; 11:253. [PMID: 19886977 PMCID: PMC2787252 DOI: 10.1186/ar2826] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Although infections are a major concern in patients with primary systemic vasculitis, actual knowledge about risk factors and evidence concerning the use of anti-infective prophylaxis from clinical trials are scarce. The use of high dose glucocorticoids and cyclophosphamide pose a definite risk for infections. Bacterial infections are among the most frequent causes of death, with Staphylococcus aureus being the most common isolate. Concerning viral infections, cytomegalovirus and varicella-zoster virus reactivation represent the most frequent complications. The only prophylactic measure that is widely accepted is trimethoprim/sulfamethoxazole to avoid Pneumocystis jiroveci pneumonia in small vessel vasculitis patients with generalised disease receiving therapy for induction of remission.
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Affiliation(s)
- Frank Moosig
- Department of Rheumatology, University Hospital of Schleswig Holstein and Klinikum Bad Bramstedt, Oskar Alexander Str, 26, 24576 Bad Bramstedt, Germany.
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Holle J, Gross W. ANCA-associated vasculitides: Pathogenetic aspects and current evidence-based therapy. J Autoimmun 2009; 32:163-71. [DOI: 10.1016/j.jaut.2009.02.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2009] [Accepted: 02/11/2009] [Indexed: 11/30/2022]
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Pneumocystose au cours des maladies systémiques. Presse Med 2009; 38:251-9. [DOI: 10.1016/j.lpm.2008.11.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2008] [Revised: 10/28/2008] [Accepted: 11/03/2008] [Indexed: 11/18/2022] Open
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Manna R, Cadoni G, Ferri E, Verrecchia E, Giovinale M, Fonnesu C, Calò L, Armato E, Paludetti G. Wegener's granulomatosis: an update on diagnosis and therapy. Expert Rev Clin Immunol 2008; 4:481-95. [PMID: 20477576 DOI: 10.1586/1744666x.4.4.481] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Wegener's granulomatosis (WG) is a unique clinicopathological disease characterized by necrotizing granulomatous vasculitis of the respiratory tract, pauci-immune necrotizing glomerulonephritis and small-vessel vasculitis. Owing to its wide range of clinical manifestations, WG has a broad spectrum of severity that includes the potential for alveolar hemorrhage or rapidly progressive glomerulonephritis, which are immediately life threatening. WG is associated with the presence of circulating antineutrophil cytoplasm antibodies (c-ANCAs). The most widely accepted pathogenetic model suggests that c-ANCA-activated cytokine-primed neutrophils induce microvascular damage and a rapid escalation of inflammation with recruitment of mononuclear cells. The diagnosis of WG is made on the basis of typical clinical and radiologic findings, by biopsy of involved organ, the presence of c-ANCA and exclusion of all other small-vessel vasculitis. Currently, a regimen consisting of daily cyclophosphamide and corticosteroids is considered standard therapy. A number of trials have evaluated the efficacy of less-toxic immunosuppressants and antibacterials for treating patients with WG, resulting in the identification of effective alternative regimens to induce or maintain remission in certain subpopulations of patients. Recent investigation has focused on other immunomodulatory agents (e.g., TNF-alpha inhibitors and anti-CD20 antibodies), intravenous immunoglobulins and antithymocyte globulins for treating patients with resistant WG.
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Affiliation(s)
- R Manna
- Clinical Autoimmunity Unit, Department of Internal Medicine, Catholic University of the Sacred Heart, Largo A Gemelli, 8-00168 Rome, Italy.
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Meuli K, Chapman P, O'Donnell J, Frampton C, Stamp L. Audit of pneumocystis pneumonia in patients seen by the Christchurch Hospital rheumatology service over a 5-year period. Intern Med J 2007; 37:687-92. [PMID: 17517083 DOI: 10.1111/j.1445-5994.2007.01382.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM The aim of the study was to review all cases of Pneumocystis carinii pneumonia (PCP) in patients seen by the Christchurch Hospital Rheumatology service over a 5-year period and to determine the annual incidence of PCP. METHODS The Canterbury Health Laboratory database was searched for rheumatology patients testing positive for PCP from 31 December 2000 to 31 December 2005. The rheumatology database was then searched to identify patients receiving the same immunosuppressant medication as those who developed PCP to determine the annual incidence of PCP in this group. RESULTS Four rheumatology patients were diagnosed with PCP during the 5-year period. Two were receiving oral methotrexate (MTX) for rheumatoid arthritis and two were receiving cyclophosphamide (CYC), one each for Wegener's granulomatosis and dermatomyositis. None of the four cases was receiving PCP chemoprophylaxis. Five hundred and forty-seven patients commenced MTX over the same 5-year period and 47 commenced CYC. Only 14 of 47 (29.7%) CYC-treated patients received PCP prophylaxis. The annual incidence of PCP was 0.17% (95% confidence interval (CI) 0.02-0.63) and 5.33% (95%CI 0.65-19.24) in patients prescribed MTX and CYC, respectively. For the 33 patients receiving CYC without concomitant PCP prophylaxis the annual incidence was 9.50% (95%CI 1.15-34.33). CONCLUSION In our study the annual incidence of PCP in patients taking MTX was low and would not support the use of routine PCP chemoprophylaxis. In patients receiving CYC without concomitant PCP chemoprophylaxis the annual incidence of PCP was higher although the number of cases was small. Given the high morbidity and mortality in this group, PCP chemoprophylaxis should be considered.
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Affiliation(s)
- K Meuli
- Department of Rheumatology, Immunology and Allergy, Christchurch Hospital, Christchurch, New Zealand
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Abstract
Wegener's granulomatosis (WG) is the most common pulmonary granulomatous vasculitis and was a uniformly fatal disease prior to the identification of efficacious pharmacological regimens. The pathogenesis of WG remains elusive but proteinase 3-specific anti-neutrophil cytoplasmic antibodies may be involved. Histologically, WG is defined by the triad of small vessel necrotising vasculitis, 'geographic' necrosis and granulomatous inflammation. Organ involvement characteristically includes the upper and lower respiratory tracts and kidney, but virtually any organ can be involved. The severity of the disease varies, ranging from asymptomatic disease to fulminant, fatal vasculitis. Similarly, the degree of organ involvement is highly variable; WG may be limited to a single organ (typically the lungs or upper respiratory tract), or may be systemic. Currently, a regimen consisting of daily cyclophosphamide and corticosteroids, which induces complete remission in the majority of patients, is considered standard therapy. Since approximately 50% of patients experience a relapse following discontinuation of therapy, alternative regimens designed to maintain remissions after using cyclophosphamide and corticosteroids are usually necessary. This 'induction maintenance' approach to treatment has emerged as a central premise in planning therapy for patients with WG.A number of trials have evaluated the efficacy of less toxic immunosuppressants (e.g. methotrexate, azathioprine, mycophenolate mofetil) and antibacterials (i.e. cotrimoxazole [trimethoprim/sulfamethoxazole]) for treating patients with WG, resulting in the identification of effective alternative regimens to induce or maintain remissions in certain sub-populations of patients. Given the efficacy of methotrexate (for early systemic WG) and cotrimoxazole (in WG limited solely to the upper airways) to induce remissions, and the relatively decreased associated morbidity compared with cyclophosphamide, these alternative regimens are preferred in appropriate patients. Similarly, therapeutic options to maintain disease remission that are less toxic than cyclophosphamide should be offered following induction of remission unless a specific contraindication exists. By following this premise, the development of cyclophosphamide-induced morbidities (e.g. haemorrhagic cystitis, uroepithelial cancers and prolonged myelosuppression) may be minimised. Recent investigation has focussed on other immunomodulatory agents (tumour necrosis factor-alpha inhibitors [infliximab and etanercept] and anti-CD20 antibodies [rituximab]) for treating patients with WG. However, the current data are conflicting and difficult to interpret. As a result, these newer agents cannot be recommended for routine use until vigorous clinical study confirms their efficacy.
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Affiliation(s)
- Eric S White
- Division of Pulmonary and Critical Medicine, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, Michigan 48109, USA.
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Li J, Huang XM, Fang WG, Zeng XJ. Pneumocystis carinii Pneumonia in Patients With Connective Tissue Disease. J Clin Rheumatol 2006; 12:114-7. [PMID: 16755237 DOI: 10.1097/01.rhu.0000221794.24431.36] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although the association of Pneumocystis carinii pneumonia (PCP) with connective tissue disease (CTD) has been noted for a long time, there are few series reported. OBJECTIVE The objective of this study was to describe clinical features and prognosis of PCP infections in patients with CTD in China. METHODS We retrospectively reviewed the characteristics, clinical features, and prognosis of PCP in patients with CTD in a single hospital. RESULTS A total of 7 cases were reviewed (systemic lupus erythematosus n = 2, microscopic polyangiitis n = 2, dermatomyositis n = 2, polymyositis n = 1). Eighty-six percent of patients developed PCP within 3 months of the diagnosis of CTD. All patients were receiving daily glucocorticoid therapy and cytotoxic drugs before the diagnosis of PCP. Most patients had fever, progressive dyspnea, and dry cough at onset of PCP. The mean duration of symptoms before PCP diagnosis was 7 days. Absolute lymphocyte counts ranged from 126 to 528/microL. The CD4 lymphocyte counts of all patients were 87 +/- 78/microL. One patient was diagnosed by induced sputum; 6 patients were diagnosed by bronchoalveolar lavage fluid. Complicating fungal infection was found in 4 of 7 patients at the time of diagnosis of PCP. All patients were treated by trimethoprim-sulfamethoxazole and corticosteroids. Six (86%) patients died. The mean duration of the time from diagnosis to death was 14 +/- 4 days. CONCLUSIONS Our results suggest that PCP is an uncommon and fatal opportunistic infection in patients with CTD. When patients with CTD who are receiving immunosuppressive therapy have low lymphocyte counts and/or CD4 lymphocyte counts less than 250/microL develop fever, dry cough, dyspnea, and chest radiography shows diffuse interstitial infiltrate, the diagnosis of PCP should be highly suspected. Induced sputum or BAL must be quickly performed to confirm diagnosis. Further study is needed as to whether earlier treatment will improve prognoses or whether patients with CTD with low CD4 counts should receive PCP prophylaxis.
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Affiliation(s)
- Jian Li
- Department of Internal Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, PR China.
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Abstract
Lymphopenia is defined as a peripheral lymphocyte count lower than 1500/mm3 in adults and 4500/mm3 in children younger than eight months of age. We propose a classification of lymphopenia according to the mechanism involved: lymphocyte production defects, including primary immune deficiencies and immune deficiencies secondary to malnutrition or zinc deprivation; excess catabolism, due to causes including radiotherapy, chemotherapy, immunosuppressive therapy, HIV infection, and systemic lupus erythematosus; abnormal lymphocyte trapping, including mainly splenomegaly, certain viral infections, septic shock, extended burns, systemic granulomatosis, and corticosteroids; other causes of lymphocytopenia, with mechanisms that remain poorly understood: ethnicity (Ethiopians), lymphoma, renal insufficiency, and idiopathic CD4 lymphocytopenia.
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Affiliation(s)
| | | | | | - Luc Mouthon
- Service de médecine interne, Hôpital Cochin, AP-HP, université Paris-Descartes, faculté de médecine, Paris (75)
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Aries PM, Hellmich B, Gross WL. [Glucocorticoids: importance in the treatment of vasculitis]. Z Rheumatol 2005; 64:155-61. [PMID: 15868332 DOI: 10.1007/s00393-005-0717-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2005] [Accepted: 02/15/2005] [Indexed: 10/25/2022]
Abstract
Only the modification of natural steroids in the middle of the last century gave insights into the structural requirements for the biological activity of the glucocorticoids (GC). While the delta-4,3-keto-11-beta, 17-alpha,21-trihydroxyl configuration is needed for the GC-activity, an artificial additional double binding in position 1 and 2 lead to a four fold increase of the GC-activity. Of the artificial GC, prednisolone is the most frequently used compound and essential in the therapy of vasculitis today. Dosage, duration and way of application depend on the diagnosis, disease stage, -extend as well as -activity. Considering the use and side-effects of the GC, experiences from cohort-studies of the late 80-ties help at clinical decision making. For giant cell arteritis (GCA) it was shown, that doses of less then 60 mg/day are needed for the induction of remission. Concerning the visual loss in GCA, time of initiating GC-therapy seems more important than the dosage. In the treatment of ANCA-associated vasculitis therapy with GC, later in combination with cyclophosphamide, lead to a significant reduction of mortality. Due to the fact of an increasing survival rate, therapy-related morbidity becomes a more and more important issue. There is a proven correlation between the dosage respectively duration of the GC-therapy and the risk of GC-associated side-effects, especially the incidence of severe infections. This article gives a short review of the present data of the role of GC in the treatment of vasculitis.
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Affiliation(s)
- P M Aries
- Universitätsklinikum Schleswig Holstein, Campus Lübeck und Rheumaklinik Bad Bramstedt, Oskar-Alexander-Strasse 26, 24576 Bad Bramstedt, Germany.
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Hellmich B, Gross WL. Difficult to diagnose manifestations of vasculitis: Does an interdisciplinary approach help? Best Pract Res Clin Rheumatol 2005; 19:243-61. [PMID: 15857794 DOI: 10.1016/j.berh.2004.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
In the early stages of disease, primary systemic vasculitides often present with non-specific symptoms that make early diagnosis a challenge. The variety of clinical manifestations found in systemic vasculitis is huge, and some manifestations are frequently not clinically overt at first presentation. A logical implication of the often non-specific and sometimes subclinical presentation of vasculitis is that a systematic diagnostic work-up is necessary. This requires a multidisciplinary approach involving the expert opinion of specialists from many disciplines, such as neurology, radiology, respiratory medicine, pathology and microbiology. There are no generally accepted diagnostic criteria for primary systemic vasculitides, and the application of classification criteria as diagnostic criteria is not feasible and may even be misleading. The demonstration of vasculitis on biopsy is still the gold standard for the diagnosis of vasculitis. In cases where biopsies cannot be obtained, surrogate parameters of vasculitis (e.g. glomerular hematuria or mononeuritis multiplex), along with serology and imaging, can support a clinical diagnosis of vasculitis. This review discusses the approach to the diagnosis of central nervous system and pulmonary manifestations of primary systemic vasculitis. These two examples of difficult to diagnose manifestations of vasculitis illustrate the necessity of an interdisciplinary approach to the diagnostic work-up.
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Affiliation(s)
- Bernhard Hellmich
- Department of Rheumatology, Poliklinik für Rheumatologie, Universitätsklinfikum Schleswig-Holstein, Campus Lübeck and Rheumaklinik Bad Bramstedt, Ratzeburger Allee 160, 23538 Lübeck, Germany.
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Rodriguez M, Fishman JA. Prevention of infection due to Pneumocystis spp. in human immunodeficiency virus-negative immunocompromised patients. Clin Microbiol Rev 2005; 17:770-82, table of contents. [PMID: 15489347 PMCID: PMC523555 DOI: 10.1128/cmr.17.4.770-782.2004] [Citation(s) in RCA: 173] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Pneumocystis infection in humans was originally described in 1942. The organism was initially thought to be a protozoan, but more recent data suggest that it is more closely related to the fungi. Patients with cellular immune deficiencies are at risk for the development of symptomatic Pneumocystis infection. Populations at risk also include patients with hematologic and nonhematologic malignancies, hematopoietic stem cell transplant recipients, solid-organ recipients, and patients receiving immunosuppressive therapies for connective tissue disorders and vasculitides. Trimethoprim-sulfamethoxazole is the agent of choice for prophylaxis against Pneumocystis unless a clear contraindication is identified. Other options include pentamidine, dapsone, dapsone-pyrimethamine, and atovaquone. The risk for PCP varies based on individual immune defects, regional differences, and immunosuppressive regimens. Prophylactic strategies must be linked to an ongoing assessment of the patient's risk for disease.
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Affiliation(s)
- Martin Rodriguez
- Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit St., GRJ 504, Boston, MA 02114, USA
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