Varicella zoster virus infections increase the risk of disease flares in patients with SLE: a matched cohort study

Intercurrent infection as a risk factor for disease flares in patients with systemic lupus erythematosus

OBJECTIVE

To determine whether intercurrent infections are a risk factor for subsequent disease flares in systemic lupus erythematosus (SLE).

METHODS

Demographic and clinical characteristics of 203 patients with SLE participating in the Amsterdam SLE cohort were collected at baseline and during follow-up. Collection of data on infections and SLE flares was registry-based and infections and flares were categorised as minor or major, based on predefined criteria. Proportional hazard models with recurrent events and time-varying covariates were used to estimate the HR of SLE flares.

RESULTS

The incidence rates of major and minor infections were 5.3 per 100 patient years and 63.9 per 100 patient years, respectively. The incidence rates of flares were 3.6 and 15.1 per 100 patient years for major flares and minor flares, respectively.In the proportional hazard model, intercurrent infections (major and minor combined) were associated with the occurrence of SLE flares (major and minor combined; HR 1.9, 95% CI: 1.3 to 2.9). The hazard ratio for a major SLE flare following a major infection was 7.4 (95% CI: 2.2 to 24.6). Major infections were not associated with the occurrence of minor flares.

CONCLUSIONS

The results of the present study show that intercurrent infections are associated with subsequent SLE flares, which supports the hypothesis that infections may trigger SLE flares.

Exploring the causal role of the immune response to varicella-zoster virus on multiple traits: a phenome-wide Mendelian randomization study

BACKGROUND

The immune response to infections could be largely driven by the individual's genes, especially in the major histocompatibility complex (MHC) region. Varicella-zoster virus (VZV) is a highly communicable pathogen. In addition to infection, the reactivations of VZV can be a potential causal factor for multiple traits. Identification of VZV immune response-related health conditions can therefore help elucidate the aetiology of certain diseases.

METHODS

A phenome-wide Mendelian randomization (MR) study of anti-VZV immunoglobulin G (IgG) levels with 1370 traits was conducted to explore the potential causal role of VZV-specific immune response on multiple traits using the UK Biobank cohort. For the robustness of the results, we performed MR analyses using five different methods. To investigate the impact of the MHC region on MR results, the analyses were conducted using instrumental variables (IVs) inside (IV_mhc) and outside (IV_no.mhc) the MHC region or all together (IV_full).

RESULTS

Forty-nine single nucleotide polymorphisms (IV_full) were associated with anti-VZV IgG levels, of which five (IV_mhc) were located in the MHC region and 44 (IV_no.mhc) were not. Statistical evidence (false discovery rate < 0.05 in at least three of the five MR methods) for a causal effect of anti-VZV IgG levels was found on 22 traits using IV_mhc, while no evidence was found when using IV_no.mhc or IV_full. The reactivations of VZV increased the risk of Dupuytren disease, mononeuropathies of the upper limb, sarcoidosis, coeliac disease, teeth problems and earlier onset of allergic rhinitis, which evidence was concordant with the literature. Suggestive causal evidence (P < 0.05 in at least three of five MR methods) using IV_full, IV_mhc and IV_no.mhc was detected in 92, 194 and 56 traits, respectively. MR results from IV_full correlated with those from IV_mhc or IV_no.mhc. However, the results between IV_mhc and IV_no.mhc were noticeably different, as evidenced by causal associations in opposite directions between anti-VZV IgG and ten traits.

CONCLUSIONS

In this exploratory study, anti-VZV IgG was causally associated with multiple traits. IVs in the MHC region might have a substantial impact on MR, and therefore, could be potentially considered in future MR studies.

Hashimoto's thyroiditis increases the risk of new-onset systemic lupus erythematosus: a nationwide population-based cohort study

BACKGROUND

Previous studies have shown systemic lupus erythematosus (SLE) patients had a significantly higher prevalence of thyroid diseases and hypothyroidism than matched controls, and some case reports showed SLE may occur after Hashimoto's thyroiditis (HT).

OBJECTIVE

This study aimed to investigate the subsequent risk of SLE in patients with HT.

METHODS

In this retrospective cohort study done by the Taiwan National Health Insurance Research Database, the HT group (exposure group) and the non-HT group (comparator group) were propensity score matched at a ratio of 1:2 by demographic data, comorbidities, medications, and the index date. We used Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). Several sensitivity analyses were done for cross-validation of our findings.

RESULTS

We identified 15,512 HT patients and matched 31,024 individuals. The incidence rate ratio of SLE was 3.58 (95% CI, 2.43-5.28; p < 0.01). Several sensitivity analyses show adjusted hazard ratio (aHR) (CIs) of 4.35 (3.28-5.76), 4.39 (3.31-5.82), 5.11 (3.75-6.98), and 4.70 (3.46-6.38), consistent with the results of the main model.

CONCLUSION

Our study showed an increased risk of SLE in the HT group after adjustment for baseline characteristics, comorbidities, and medical confounders compared with the reference group.

Epidemiological Characteristics of Varicella under Different Immunisation Strategies in Suzhou Prefecture, Jiangsu Province

Background: The varicella vaccine is excluded from the Chinese national immunisation programme but is included in the local expanded programme on immunisation (EPI) in the Suzhou Prefecture. This study investigated the epidemiological characteristics of the varicella cases during the implementation of different immunisation strategies in the Suzhou Prefecture, Jiangsu Province. Methods: In this study, we used descriptive statistics. Information on reported instances from 2012 to 2021 was first retrieved. Data on varicella cases were collected from the China Information System for Disease Control and Prevention (CISDCP). Similarly, information on vaccinated children was obtained from the Jiangsu Province Vaccination Integrated Service Management Information System (JPVISMIS). The census data in this study was procured from the Suzhou Bureau of Statistics. Results: From 2012 to 2021, a total of 118,031 cases of varicella were reported in Suzhou, and the average annual reported incidence was 91.35 per 100,000. The average yearly incidence after implementing the two-dose varicella vaccination decreased by 41.57% compared with the implementation of one dose. This study demonstrates two annual incidence peaks, a small peak between April and July and a prominent peak between October and January. It is also possible that this seasonal distribution is related to the geography of Suzhou. The average annual reported incidence between districts with a statistically significant difference (χ2 = 98.077, p < 0.05). The one-dose varicella vaccination coverage gradually increased from 55.34% in 2012 to 89.06% in 2021 and the two-dose varicella vaccination coverage gradually increased from 0.27% in 2012 to 82.17% in 2021. Conclusions: Administering the varicella vaccine in the local EPI has significantly decreased the incidence rate and the total number of cases. A two-dose vaccination schedule is still the best vaccination strategy for varicella vaccine effectiveness.

Low-dose belimumab for patients with systemic lupus erythematosus at low disease activity: protocol for a multicentre, randomised, double-blind, placebo-controlled clinical trial

INTRODUCTION

SLE is a chronic inflammatory systemic autoimmune disease with relapsing-remitting pattern. B-lymphocyte stimulator was involved in the pathogenesis of SLE. The humanised monoclonal antibody belimumab with 10 mg/kg was effective for active patients. However, the efficacy of low-dose belimumab for prevention of disease flares in patients with SLE with low disease activity is to be explored.

METHODS AND ANALYSIS

This is a multicentre, randomised, double-blind, placebo-controlled clinical trial. Patients who have Safety of Estrogens in Lupus Erythematosus National Assessment-Systemic Lupus Erythematosus Disease Activity Index (SELENA-SLEDAI) scores no higher than 6; with no A score or no more than one B score on the British Isles Lupus Assessment Group (BILAG) scale; and who are treated with prednisone (≤20 mg per day) at screening will be enrolled. 334 adults will be randomly assigned in a 1:1 ratio to receive intravenous 120 mg belimumab or placebo (saline) arm on weeks 0, 2, and 4, and then every 4 weeks until 48 weeks, with standard of care. The primary outcome measure is a composite index of severe or mild-to-moderate disease flares (SELENA-SLEDAI Flare Index) within 52 weeks. Secondary outcomes include the percentage of severe flare, the percentage of mild-to-moderate flare, time to first disease flare, changes in prednisone dose, SELENA-SLEDAI, as well as BILAG score, the percentage of patients achieving prednisone free and safety analysis.

ETHICS AND DISSEMINATION

The protocol has been approved by the Ethics Committee of the Renji Hospital, Huashan Hospital and the Sixth People's Hospital. The trial has been registered and the detailed information is available at https://clinicaltrialsgov/ct2/show/NCT04515719. The results of this clinical trial will be submitted for publication in peer-reviewed journals and key findings will also be presented at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT04515719.

Association Between a History of Nontyphoidal Salmonella and the Risk of Systemic Lupus Erythematosus: A Population-Based, Case-Control Study

Objective

We investigated the correlation between nontyphoidal Salmonella (NTS) infection and systemic lupus erythematosus (SLE) risk.

Methods

This case-control study comprised 6,517 patients with newly diagnosed SLE between 2006 and 2013. Patients without SLE were randomly selected as the control group and were matched at a case-control ratio of 1:20 by age, sex, and index year. All study individuals were traced from the index date back to their NTS exposure, other relevant covariates, or to the beginning of year 2000. Conditional logistic regression analysis was used to analyze the risk of SLE with adjusted odds ratios (aORs) and 95% confidence intervals (CIs) between the NTS and control groups.

Results

The mean age was 37.8 years in the case and control groups. Females accounted for 85.5%. The aOR of having NTS infection were significantly increased in SLE relative to controls (aOR, 9.20; 95% CI, 4.51-18.78) in 1:20 sex-age matching analysis and (aOR, 7.47; 95% CI=2.08-26.82) in propensity score matching analysis. Subgroup analysis indicated that the SLE risk was high among those who dwelled in rural areas; had rheumatoid arthritis, multiple sclerosis, or Sjogren’s syndrome; and developed intensive and severe NTS infection during admission.

Conclusions

Exposure to NTS infection is associated with the development of subsequent SLE in Taiwanese individuals. Severe NTS infection and other autoimmune diseases such as rheumatoid arthritis, multiple sclerosis, or Sjogren’s syndrome also contributed to the risk of developing SLE.

Metagenomic analysis of a throat swab sample collected in China on a patient infected with Varicella Zoster Virus

Varicella Zoster Virus (VZV) is endemic worldwide, causing varicella in children and zoster upon reactivation in adults. This study concerned a metagenomic analysis of a throat swab sample collected in China, on a young patient suffering from Systemic Lupus Erythematosus (SLE) and diagnosed with varicella. The complete genome sequence of a VZV strain of clade 2 has been generated. Clade 2 strains are the most prevalent in Asian countries. A comparison of 223 VZV genomes identified 77 clade specific markers, 20 of them specific to clade 2. The metagenomic analysis also identified sequences covering most of the genome of the bacteria Schaalia odontolytica also known as Actinomyces odontolyticus. VZV infection and bacterial infection in the context of SLE is further discussed. Even though the patient presented only mild symptoms, this study is a reminder that vaccination against VZV is critical to avoid severe complications like bacterial superinfection or even death in the case of immunodeficiency.

COVID-19 in patients with systemic lupus erythematosus: lessons learned from the inflammatory disease

As the world navigates the coronavirus disease 2019 (COVID-19) pandemic, there is a growing need to assess its impact in patients with autoimmune rheumatic diseases, such as systemic lupus erythematosus (SLE). Patients with SLE are a unique population when considering the risk of contracting COVID-19 and infection outcomes. The use of systemic glucocorticoids and immunosuppressants, and underlying organ damage from SLE are potential susceptibility factors. Most patients with SLE have evidence of high type I interferon activity, which may theoretically act as an antiviral line of defense or contribute to the development of a deleterious hyperinflammatory response in COVID-19. Other immunopathogenic mechanisms of SLE may overlap with those described in COVID-19, thus, studies in SLE could provide some insight into immune responses occurring in severe cases of the viral infection. We reviewed the literature to date on COVID-19 in patients with SLE and provide an in-depth review of current research in the area, including immune pathway activation, epidemiology, clinical features, outcomes, and the psychosocial impact of the pandemic in those with autoimmune disease.

Interferon-stimulated GTPases in autoimmune and inflammatory diseases: promising role for the guanylate-binding protein (GBP) family

Human IFNs are secreted cytokines shown to stimulate the expression of over one thousand genes. These IFN-inducible genes primarily encode four major protein families, known as IFN-stimulated GTPases (ISGs), namely myxovirus-resistance proteins, guanylate-binding proteins (GBPs), p47 immunity-related GTPases and very large inducible guanosine triphosphate hydrolases (GTPases). These families respond specifically to type I or II IFNs and are well reported in coordinating immunity against some well known as well as newly discovered viral, bacterial and parasitic infections. A growing body of evidence highlights the potential contributory and regulatory roles of ISGs in dysregulated inflammation and autoimmune diseases. Our focus was to draw attention to studies that demonstrate increased expression of ISGs in the serum and affected tissues of patients with RA, SS, lupus, IBD and psoriasis. In this review, we analysed emerging literature describing the potential roles of ISGs, particularly the GBP family, in the context of autoimmunity. We also highlighted the promise and implications for therapeutically targeting IFNs and GBPs in the treatment of rheumatic diseases.

Safety and efficacy of metformin in systemic lupus erythematosus: a multicentre, randomised, double-blind, placebo-controlled trial

BACKGROUND

Immunometabolism is involved in the pathogenesis of systemic lupus erythematosus (SLE). The aim of this study was to repurpose metformin, an anti-diabetic drug that regulates systemic and cellular metabolism, and assess its effects in Chinese patients with SLE without diabetes.

METHODS

We did a multicentre, randomised, double-blind, placebo-controlled trial in three hospitals in Shanghai, China. We enrolled adult patients with SLE, without diabetes, who had Safety of Estrogens in Lupus Erythematosus National Assessment-Systemic Lupus Erythematosus Disease Activity Index (SELENA-SLEDAI) scores no higher than 6; with no A score or no more than one B score on the British Isles Lupus Assessment Group (BILAG) scale at screening; who had had at least one lupus flare; and were treated with prednisone (≥20 mg per day) within the preceding 12 months. Patients were randomly assigned (1:1) in blocks of four by a computer algorithm to add metformin tablets (250 mg per tablet with a target dose of 0·5 g three times per day; metformin group) or placebo tablets (placebo group) to their standard therapy, for a maximum of 12 months. Patients, assessment staff, and statisticians were masked to group assignment. The primary endpoint was a composite index of major or mild-to-moderate disease flares (SELENA-SLEDAI Flare Index) at 12 months. The full analyses were done in all patients who received at least one dose of the study drug using the χ2 test. Adverse events were recorded during the 12-month follow-up. This study is registered with ClinicalTrials.gov, NCT02741960.

FINDINGS

Between May 24, 2016, and Dec 13, 2017, 180 patients were screened, of whom 140 (78%) of them were enrolled. 31 (17%) did not meet the inclusion criteria and nine (5%) withdrew informed consent without treatment after randomisation. 67 patients were assigned to the metformin group and 73 to the placebo group. By 12 months of follow-up, there was no significant difference in the incidence of lupus flares, which occurred in 14 (21%) patients in the metformin group versus 25 (34%) in the placebo group (relative risk 0·68, 0·42-1·04, p=0·078). Patients receiving metformin experienced more gastrointestinal adverse events (three [4%] discontinued for this reason vs one [1%] for placebo; overall 26 [39%] vs 11 [15%], p=0·0015), but the incidence of non-flare serious adverse events was similar between groups (one [1%] vs three [4%], p=0·35). The frequency of infection events was significantly lower in patients in the metformin group than in the placebo group (17 [25%] vs 32 [44%], p=0·022). No patients died as a result of treatment.

INTERPRETATION

This trial was underpowered to draw a sound conclusion on the efficacy of metformin to reduce disease flares as an add-on treatment to standard care in patients with SLE. Nonetheless, metformin had a favourable safety profile and our data present a basis for larger trials to investigate its potential effect on reducing the frequency of flares for patients with SLE with low-grade disease activity who are at risk of relapse.

FUNDING

Shanghai Shenkang Promoting Project and the National Key Research and Development Program of China.