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Qian Y, Zhang Y, Huang J, Liu J, Chen G, Xia G, Wang C, Feng A, Chen Y, Chen J, Zeng Y, Nie X. Risk Factors for Pneumocystis jirovecii Pneumonia in Children With Systemic Lupus Erythematosus Exposed to Prolonged High-Dose Glucocorticoids. J Clin Rheumatol 2024:00124743-990000000-00189. [PMID: 38389131 DOI: 10.1097/rhu.0000000000002073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PJP) is a life-threatening opportunistic infection in immunocompromised children with systemic lupus erythematosus (SLE). Prophylaxis against PJP in high-risk children is crucial, but the risk factors for PJP in children with SLE are not adequately characterized. This study sought to identify the risk factors for PJP in long-term glucocorticoid-treated pediatric SLE patients. METHODS This study encompassed 71 treatment episodes involving 64 children with prolonged (≥4 weeks) high-dose (≥20 mg/d prednisone) steroid regimens. Fourteen treatment episodes involved the PJP, whereas others did not. Risk factors for PJP were assessed through Cox regression. The predictive value of these factors was evaluated using receiver operating characteristic curves. The incidence of PJP in different risk groups was compared using the Kaplan-Meier method. RESULTS The creatinine (hazard ratio, 1.009; 95% confidence interval [CI], 1.001-1.017; p = 0.021) and the lowest lymphocyte count (hazard ratio, 0.007; 95% CI, 0.000-0.373; p = 0.014) were independent risk factors for PJP in children with SLE. The receiver operating characteristic curve showed that using creatinine greater than 72.5 μmol/L and the lowest lymphocyte count less than 0.6 × 109/L as risk predictors for PJP resulted in an area under the curve value of 0.934 (95% CI, 0.870-0.997; p < 0.001). The study revealed a significant increase in PJP prevalence (p < 0.001) in children with elevated creatinine levels and low lymphocyte count. CONCLUSIONS Elevated levels of creatinine and decreased lymphocyte count are identified as distinct risk factors for PJP in children with SLE who receive prolonged high-dose steroid therapy.
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Affiliation(s)
| | | | | | - Jingjing Liu
- Department of Pediatrics, The 900th Hospital of the Joint Logistic Support Force, Fuzhou, China
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Chen X, Shu X, He L, Yang H, Lu X, Wang G, Ge Y. High prevalence and mortality of Pneumocystis jirovecii pneumonia in anti-MDA5 antibody-positive dermatomyositis. Rheumatology (Oxford) 2023; 62:3302-3309. [PMID: 36734589 DOI: 10.1093/rheumatology/kead063] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 01/15/2023] [Accepted: 01/26/2023] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES To identify potential risk factors and prognostic factors of Pneumocystis jirovecii pneumonia (PJP) infection in anti-melanoma differentiation-associated gene 5 antibody-positive DM (anti-MDA5+ DM) patients, and to evaluate the diagnostic performance of metagenomic next-generation sequencing (mNGS). METHODS Anti-MDA5+ DM patients who underwent mNGS or real-time PCR for PJP detection were recruited. The potential risk factors for PJP occurrence and death were analysed via Logistic regression and Cox proportional hazards regression, respectively. The diagnostic efficacy of mNGS was compared with the conventional methods. RESULTS 91 patients were enrolled and 44 were assigned to PJP+ group. The PJP detection rate was 48.4%. PJP often occurred in the first 3 months (68.2%) of the disease; this period also showed the highest mortality rate (20.5%). Fever and increased lactate dehydrogenase (LDH) were independent risk factors for PJP occurrence, while trimethoprim-sulfamethoxazole (TMP/SMZ) prophylaxis was an independent protective factor (all P < 0.05). Older age and increased LDH were predictors for mortality in patients with anti-MDA5+ DM and PJP (all P < 0.05). In addition, we found that mNGS had a sensitivity of 100.0% and specificity of 90.0% in diagnosing PJP, with the highest area under the curve of 0.95 (P < 0.001). CONCLUSION PJP has high prevalence and mortality in anti-MDA5+ DM. It is crucial for clinicians to identify high-risk patients and promptly institute TMP/SMZ to prevent PJP. mNGS is the preferred approach for pathogen detection in anti-MDA5+ DM when PJP is suspected.
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Affiliation(s)
- Xixia Chen
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Xiaoming Shu
- Department of Rheumatology, Key Myositis Laboratories, China-Japan Friendship Hospital, Beijing, China
| | - Linrong He
- Department of Rheumatology, Key Myositis Laboratories, China-Japan Friendship Hospital, Beijing, China
| | - Hanbo Yang
- Department of Rheumatology, Key Myositis Laboratories, China-Japan Friendship Hospital, Beijing, China
| | - Xin Lu
- Department of Rheumatology, Key Myositis Laboratories, China-Japan Friendship Hospital, Beijing, China
| | - Guochun Wang
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
- Department of Rheumatology, Key Myositis Laboratories, China-Japan Friendship Hospital, Beijing, China
| | - Yongpeng Ge
- Department of Rheumatology, Key Myositis Laboratories, China-Japan Friendship Hospital, Beijing, China
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Sadeghi Haddad Zavareh M, Mehdinezhad H, Mehraeen R, Golparvar Azizi M, Tavakoli Pirzaman A. Pneumocystis jirovecii pneumonia complicated a case of SARS-CoV-2 infection and multiple sclerosis after treatment with rituximab. Clin Case Rep 2023; 11:e7455. [PMID: 37273666 PMCID: PMC10238708 DOI: 10.1002/ccr3.7455] [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: 02/01/2023] [Revised: 04/29/2023] [Accepted: 05/18/2023] [Indexed: 06/06/2023] Open
Abstract
Although immunodeficient patients are less prone to develop Coronavirus disease 2019 (COVID-19)-mediated cytokine storm, secondary infections can cause serious complications in this vulnerable population. They are more likely to develop opportunistic infections that can mimic the symptoms of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Herein, we presented a 27-year-old male patient of SARS-CoV-2 infection, who was complicated with Pneumocystis jirovecii pneumonia (PJP), following treatment with rituximab. First, he was hospitalized for 5 days with fever, cough, and dyspnea due to COVID-19 infection, and treated with remdesivir and glucocorticoid. Then, he has been referred to our center with cough, dyspnea, body pain, and fever. Due to persistent fever, the progression of pulmonary lesions, and reduced oxygen saturation, we began treatment with piperacillin + tazobactam, vancomycin, and levofloxacin. Nevertheless, the patient's fever did not stop after the aforementioned empiric treatment and his condition got worse and he was admitted to the intensive care unit. The result of BAL fluid, tested for P. jirovecii by RT-PCR, turned out to be positive. Therefore, we started trimethoprim-sulfamethoxazole and dexamethasone, which improved his condition. We hope this article helps clinicians consider causes other than COVID-19, especially opportunistic infections such as PJP, in patients with respiratory symptoms and fever.
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Affiliation(s)
- Mahmoud Sadeghi Haddad Zavareh
- Infectious Diseases and Tropical Medicine Research Center, Health Research InstituteBabol University of Medical SciencesBabolIran
| | - Hamed Mehdinezhad
- Department of Internal Medicine, Rouhani HospitalBabol University of Medical SciencesBabolIran
| | - Rahele Mehraeen
- Department of Radiology, Rohani HospitalBabol University of Medical SciencesBabolIran
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Pneumocystis jirovecii pneumonia in autoimmune rheumatic diseases: a nationwide population-based study. Clin Rheumatol 2021; 40:3755-3763. [PMID: 33646447 PMCID: PMC7917170 DOI: 10.1007/s10067-021-05660-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 02/08/2021] [Accepted: 02/16/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To compare Pneumocystis jirovecii pneumonia (PJP) risk between patients with autoimmune rheumatic diseases (ARD) and the general population METHODS: We identified patients with ARD recorded in the National Health Insurance Research Database of Taiwan from 2002 to 2015 and randomly selected a comparison cohort from the general population matched for age and sex. We analyzed PJP risk stratified by sex, age, comorbidities, and medications using Cox proportional hazard model. RESULTS We enrolled 103,117 patients with ARD. PJP risk significantly increased in patients with any ARD and with each individual ARD like rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Sjogren's syndrome (SjS), polymyositis and dermatomyositis (PM/DM), systemic sclerosis (SSc), and systemic vasculitis. Patients with PM/DM showed prominent risk with incidence rate of 12.47/100,000 patient year (95% confidence interval (CI), 32.16-86.70). In a time-dependent Cox proportional hazard model with comorbidities and medications as covariates, PM/DM, SSc, SLE, and SjS significantly increased adjusted hazard ratios (aHR) of 5.40, 5.12, 4.09, and 3.64, respectively (95% CI of 2.82-10.35, 2.16-12.13, 2.41-6.95, and 2.06-6.42, respectively). AHR after adjusting for male sex, cancer, human immunodeficiency virus infection (HIV), and interstitial lung disease also significantly increased. Use of daily oral steroid dose of >10 mg conferred the highest risk followed by mycophenolate. Use of injected steroids, cyclophosphamide, biological agents, methotrexate, and cyclosporine conferred a significantly higher risk. CONCLUSION Underlying ARD significantly predisposes patients to PJP, with PM/DM posing the highest threat. In addition to underlying disease, comorbidities and concomitant immunosuppressants are major risks. The strongest risk is recent daily steroid dose of >10 mg. Mycophenolate seems to be a more prominent risk factor than cyclophosphamide. Key Points • Autoimmune rheumatic diseases (ARD) significantly increased the overall risk of PJP, and so did each individual ARD. • Use of steroids, mycophenolate, cyclophosphamide, biological agents, methotrexate, and cyclosporine all significantly increased risk of PJP. • Male, elderly, malignancy, HIV, and interstitial lung disease are also related to increased risk of PJP. • Underlying ARD, comorbidities, and use of immunosuppressant should all be considered in determining the overall risk of PJP.
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Wang WH, Lai CC, Huang YF, Li TH, Tsao YP, Chen WS, Chang YS. Pneumocystis jirovecii pneumonia in systemic lupus erythematosus: a nationwide cohort study in Taiwan. Arthritis Care Res (Hoboken) 2021; 74:1444-1450. [PMID: 33645012 DOI: 10.1002/acr.24584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 01/18/2021] [Accepted: 02/23/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To evaluate PJP infection risk in patients with SLE in Taiwan. METHODS We identified 24,367 patients with SLE from the National Health Insurance research database between 1997 and 2012 and compared the PJP incidence rates (IRs) with those in 243,670 age- and sex-matched non-SLE controls. PJP risk in the patients was evaluated using a Cox multivariate proportional hazards model. RESULTS The patients exhibited a significantly higher PJP risk than the controls, with an IR of 2.63 per 10,000 person-years and IR ratio of 27.65 (95% CI 17.2-45.3, p < 0.001). Male sex (hazard ratio [HR] 2.42, p < 0.01), end-stage renal disease (ESRD; HR 1.74, p = 0.01), recent use of mycofenolate mofetil (MMF; HR 4.43, P < 0.001), intravenous steroid pulse therapy (HR 108.73, p < 0.001), and average oral dose of >7.5 mg/day prednisolone or equivalent (HR 4.83, p < 0.001) were associated with PJP in SLE, whereas hydroxychloroquine use reduced its risk (HR 0.51, p = 0.01). Of note, cyclophosphamide was not associated with PJP infection in the multivariate Cox proportional hazard model. CONCLUSIONS Patients with SLE have a considerably high PJP risk. Cyclophosphamide does not increase PJP risk. Male sex, ESRD, MMF use, intravenous steroid pulse therapy, oral prednisolone or equivalent (>7.5 mg/day) are risk factors for PJP, whereas hydroxychloroquine use reduces PJP risk.
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Affiliation(s)
- Wen-Hsiu Wang
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, Mackay Medical College, New Taipei City, Taiwan.,Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan
| | - Chien-Chih Lai
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yi-Fan Huang
- Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Taitung Mackay Memorial Hospital, Taitung, Taiwan
| | - Tzu-Hao Li
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Chiayi Branch, Taichung Veterans General Hospital, Taiwan
| | - Yen-Po Tsao
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Sheng Chen
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Sheng Chang
- Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Alexandre K, Ingen-Housz-Oro S, Versini M, Sailler L, Benhamou Y. Pneumocystis jirovecii pneumonia in patients treated with rituximab for systemic diseases: Report of 11 cases and review of the literature. Eur J Intern Med 2018; 50:e23-e24. [PMID: 29198498 DOI: 10.1016/j.ejim.2017.11.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 11/23/2017] [Accepted: 11/28/2017] [Indexed: 11/27/2022]
Affiliation(s)
- K Alexandre
- Department of Infectious Disease, Rouen University Hospital, Rouen F-76031, France.
| | | | - M Versini
- Department of Internal Medicine, Archet Hospital, Nice, France
| | - L Sailler
- Department of Internal Medicine, Purpan University Hospital, Toulouse, France
| | - Y Benhamou
- Department of Internal Medicine, Rouen University Hospital, Rouen F-76031, France; Inserm, U1096, Rouen, F-76000, France
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Kyriakidis I, Tragiannidis A, Zündorf I, Groll AH. Invasive fungal infections in paediatric patients treated with macromolecular immunomodulators other than tumour necrosis alpha inhibitors. Mycoses 2017; 60:493-507. [DOI: 10.1111/myc.12621] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/06/2017] [Accepted: 03/07/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Ioannis Kyriakidis
- 2nd Department of Pediatrics; Aristotle University of Thessaloniki; AHEPA University General Hospital; Thessaloniki Greece
| | - Athanasios Tragiannidis
- 2nd Department of Pediatrics; Aristotle University of Thessaloniki; AHEPA University General Hospital; Thessaloniki Greece
| | - Ilse Zündorf
- Institute of Pharmaceutical Biology; Goethe-University of Frankfurt; Frankfurt am Main Germany
| | - Andreas H. Groll
- Infectious Disease Research Program; Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology; University Childrens Hospital; Muenster Germany
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Jiang X, Mei X, Feng D, Wang X. Prophylaxis and Treatment of Pneumocystis jiroveci Pneumonia in Lymphoma Patients Subjected to Rituximab-Contained Therapy: A Systemic Review and Meta-Analysis. PLoS One 2015; 10:e0122171. [PMID: 25909634 PMCID: PMC4409297 DOI: 10.1371/journal.pone.0122171] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Accepted: 02/08/2015] [Indexed: 12/27/2022] Open
Abstract
Pneumocystis jiroveci pneumonia (PCP) is frequently reported in lymphoma patients treated with rituximab-contained regimens. There is a trend toward a difference in PCP risk between bi- and tri-weekly regimens. The aims of this systemic review and meta-analysis were to estimate the risk for PCP in these patients, compare the impact of different regimens on the risk, and evaluate the efficacy of prophylaxis. The cohort studies with incept up to January 2014 were retrieved from the Cochrane Library, Medline, Embase, and Web of Science databases. Studies that compared the incidence of PCP in patients with and without rituximab treatment were conducted. Studies that reported the results of prophylaxis were concentrated to evaluate the efficacy of prophylaxis. Fixed effect Mantel-Haenszel model was chosen as the main analysis method. Funnel plots were examined to estimate the potential selection bias. Egger's test and Begg's test were used for the determination of possible small study bias. Eleven cohort studies that met the inclusion criteria were finally included. Results indicated that rituximab was associated with a significantly increased risk for PCP (28/942 vs 5/977; risk ratio: 3.65; 95% confidence interval 1.65 to 8.07; P=0.001), and no heterogeneity existed between different studies (I2=0%). Little significant difference in PCP risk was found between bi-weekly and tri-weekly regimens (risk ratio: 3.11; 95% confidence interval 0.92 to 10.52, P=0.068). PCP risk was inversely associated with prophylaxis in patients treated with rituximab (0/222 vs 26/986; risk ratio: 0.28; 95% confidence interval 0.09 to 0.94; P=0.039). In conclusion, PCP risk was increased significantly in lymphoma patients subjected to rituximab-contained chemotherapies. Difference in PCP risk between bi-weekly and tri-weekly regimens was not significant. Additionally, prophylaxis was dramatically effective in preventing PCP in rituximab-received lymphoma patients, suggesting that rituximab should be recommended for these patients.
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Affiliation(s)
- Xuqin Jiang
- Department of Respiratory Medicine, Anhui Provincial Hospital, Hefei, China
| | - Xiaodong Mei
- Department of Respiratory Medicine, Anhui Provincial Hospital, Hefei, China
| | - Di Feng
- Department of Respiratory Medicine, Anhui Provincial Hospital, Hefei, China
| | - Xiaojing Wang
- Department of Respiratory Medicine, Anhui Provincial Hospital, Hefei, China
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Abstract
Systemic lupus erythematosus (SLE) is a clinically diverse and potentially life-threatening auto-immune disease that can affect almost any organ system. Although much is still unknown regarding its pathogenesis, B cell abnormalities are thought to be central. A high relapse rate along with the toxicity associated with conventional treatments signify the need for more tailored approaches in this very heterogeneous disease. Both its mechanism targeting B cells and a relatively large number of case series and observational studies have suggested that the B cell-depleting agent rituximab could be a potent SLE drug. However, two randomized controlled trials failed to meet efficacy endpoints. Nevertheless, rituximab has continued to be used as an off-label alternative mainly in patients refractory to conventional immunosuppressive treatment. This article will review the current role of rituximab in SLE.
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Affiliation(s)
- Sara Linder Ekö
- Unit for Clinical Therapy Research, Inflammatory Diseases (ClinTRID), Karolinska Institute, 171 76, Stockholm, Sweden,
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Fervenza FC, Perazella MA, Choi MJ. American Society of Nephrology Quiz and Questionnaire 2013: Glomerulonephritis. Clin J Am Soc Nephrol 2014; 9:987-96. [DOI: 10.2215/cjn.11571113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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11
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Caza T, Oaks Z, Perl A. Interplay of Infections, Autoimmunity, and Immunosuppression in Systemic Lupus Erythematosus. Int Rev Immunol 2014; 33:330-63. [DOI: 10.3109/08830185.2013.863305] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Perez-Ordoño L, Hoyo I, Sanclemente G, Ricart M, Cofan F, Perez-Villa F, de la Bellacasa JP, Moreno A, Cervera C. Late-onsetPneumocystis jiroveciipneumonia in solid organ transplant recipients. Transpl Infect Dis 2014; 16:324-8. [DOI: 10.1111/tid.12184] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 06/13/2013] [Accepted: 07/15/2013] [Indexed: 11/30/2022]
Affiliation(s)
- L. Perez-Ordoño
- Department of Infectious Diseases; Hospital Clinic de Barcelona-University of Barcelona; Barcelona Spain
| | - I. Hoyo
- Department of Infectious Diseases; Hospital Clinic de Barcelona-University of Barcelona; Barcelona Spain
| | - G. Sanclemente
- Department of Infectious Diseases; Hospital Clinic de Barcelona-University of Barcelona; Barcelona Spain
| | - M.J. Ricart
- Renal Transplant Unit; Hospital Clinic de Barcelona-University of Barcelona; Barcelona Spain
| | - F. Cofan
- Renal Transplant Unit; Hospital Clinic de Barcelona-University of Barcelona; Barcelona Spain
| | - F. Perez-Villa
- Heart Transplant Unit; Hospital Clinic de Barcelona-University of Barcelona; Barcelona Spain
| | - J. Puig de la Bellacasa
- Department of Microbiology; “Centre Diagnòstic Biomèdic” (CDB); Centre for International Health Research (CRESIB); Hospital Clinic de Barcelona-University of Barcelona; Barcelona Spain
| | - A. Moreno
- Department of Infectious Diseases; Hospital Clinic de Barcelona-University of Barcelona; Barcelona Spain
| | - C. Cervera
- Department of Infectious Diseases; Hospital Clinic de Barcelona-University of Barcelona; Barcelona Spain
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Bonilla-Abadía F, Betancurt JF, Pineda JC, Vélez JD, Tobón GJ, Cañas CA. Pneumocystis jirovecii pneumonia in two patients with systemic lupus erythematosus after rituximab therapy. Clin Rheumatol 2014; 33:415-8. [PMID: 24402739 DOI: 10.1007/s10067-013-2475-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 06/30/2013] [Accepted: 12/22/2013] [Indexed: 11/30/2022]
Abstract
New cases of Pneumocystis jirovecii pneumonia (PJP) have recently been reported in patients with systemic lupus erythematosus (SLE) after rituximab therapy. Several factors may contribute to susceptibility to P. jirovecii infection in this type of patients, including the immunological characteristics of the disease, the mechanisms of rituximab action, environmental factors, and the biological characteristics of the fungus. We report two patients with SLE who developed PJP after rituximab therapy.
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Affiliation(s)
- F Bonilla-Abadía
- Rheumatology Unit, Cra. 98N. 18-49, Fundación Valle del Lili-ICESI University, Cali, Colombia
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Alberici F, Jayne DRW. Impact of rituximab trials on the treatment of ANCA-associated vasculitis. Nephrol Dial Transplant 2013; 29:1151-9. [PMID: 24126571 DOI: 10.1093/ndt/gft318] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
ANCA-associated vasculitis (AAV) is a subgrouping of autoimmune disorders characterized by a chronic relapsing course. Induction therapy is usually effective, but 70% of patients will relapse and 20% develop refractory disease. In the relapsing and refractory subgroups, treatment is complicated by the cumulative exposure to toxic drugs that contribute to poor long-term outcomes. The anti-CD20 monoclonal antibody rituximab (RTX) depletes B cells, and the success of this targeted therapy has contributed to the evidence supporting a central role for B cells in AAV pathogenesis. Initial proof of RTX effectiveness originated from small, prospective trials and retrospective surveys conducted in AAV patients with relapsing and refractory disease; high remission rates permitted the reduction of glucocorticoids (GCS) doses and withdrawal of immunosuppressives. There has been controversy over the effectiveness of RTX in patients with predominantly granulomatous manifestations, where response rates have varied between studies, in part due to different RTX dosing regimens. These studies were followed by comparison of RTX against cyclophosphamide (CYC) for remission induction of new or relapsing AAV in two randomized trials, which led to the licensing of RTX for this indication. Subsequent attention has been turned to the use of RTX as a relapse prevention agent, to the potential for GCS sparing and to RTX-associated toxicity. We will discuss the impact that the results of RTX clinical trials have had on the management of AAV patients.
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Affiliation(s)
| | - David R W Jayne
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK
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Martin-Garrido I, Carmona EM, Specks U, Limper AH. Pneumocystis pneumonia in patients treated with rituximab. Chest 2013; 144:258-265. [PMID: 23258406 DOI: 10.1378/chest.12-0477] [Citation(s) in RCA: 126] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Pneumocystis pneumonia (PcP) is an opportunistic fungal infection. Although T-cell immunity is classically related to Pneumocystis defense, recent data support roles for B lymphocytes in the development of PcP in animals, and we have observed several cases of PcP in patients receiving rituximab. These observations prompted a systematic review of our experience to define the spectrum of clinical presentations in which PcP has occurred in the setting of rituximab therapy. METHODS Using a computer-based search, we reviewed the records of patients who received rituximab and developed PcP at Mayo Clinic Rochester over the years 1998 to 2011 to establish the underlying conditions, clinical course, possible risk factors, and potential association between this drug and the development of PcP. RESULTS Over this period, 30 patients developed PcP during treatment with rituximab. The underlying diseases included hematologic malignancies in 90% of cases. Glucocorticoids were used in 73% of these patients, under different chemotherapeutic regimens. Three patients (10%) developed PcP in the setting of rituximab without concomitant chemotherapy or significant glucocorticoid exposure. Of these 30 patients, 88% developed acute hypoxemic respiratory failure and 53% required ICU admission. The clinical course was fatal in 30%. CONCLUSION PcP can occur in association with rituximab, with the majority of cases having also received cytotoxic chemotherapy or significant doses of glucocorticoids. The clinical course of cases of PcP in patients treated with rituximab can be quite fulminant, with significant mortality. Primary prophylaxis should be considered in patients at risk, and secondary prophylaxis provided unless immune reconstitution is well assured.
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Affiliation(s)
- Isabel Martin-Garrido
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN; Servicio de Medicina Interna, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Eva M Carmona
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Andrew H Limper
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN.
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Jiang XQ, Fang L, Mei XD, Wang XJ, Bao MH. Pneumocystis jiroveci pneumonia in patients with non-Hodgkin's lymphoma after Rituximab-containing regimen: two cases of report and literature review. J Thorac Dis 2013; 5:E162-6. [PMID: 23991330 DOI: 10.3978/j.issn.2072-1439.2013.08.35] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 08/16/2013] [Indexed: 11/14/2022]
Abstract
Rituximab, a monoclonal antibody against CD20+ antigen specific B cell, has been increasingly used in the treatment of non-Hodgkin's lymphoma and some other autoimmune diseases, such as systemic lupus erythematosus (SLE) and rheumatoid arthritis. It is noted that Rituximab could enhanced the efficacy of CHOP-based chemotherapy. Meanwhile it could increase the opportunity of lung infection. Pneumocystis jiroveci pneumonia (PCP), a rare opportunistic infection that was not reported in the large-scale clinical trials of Rituximab, was found recently in patients with non-Hodgkin's lymphoma treated with remedy containing Rituximab. We herein report two cases of PCP in lymphoma patients after Rituximab-containing chemotherapy. Both patients were successfully treated, with trimethoprim-sulfamethoxazole (TMP-SMX) in one case and Caspofungin alone in the other. We also reviewed the literature and concluded that PCP is an infrequent but potentially life-threatening infection in patients with non-Hodgkin's lymphoma subjected to Rituximab-containing regimen. Therefore, adequate prophylaxis, timely diagnosis and treatment are necessary.
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Affiliation(s)
- Xu-Qin Jiang
- Department of Respiratory Medicine, Anhui Provincial Hospital, Hefei 230001, China
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Pneumocystis jirovecii Pneumonia in Systemic Lupus Erythematosus From Southern Taiwan. J Clin Rheumatol 2013; 19:252-8. [DOI: 10.1097/rhu.0b013e31829d5017] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Castillo RD, De la Pena W, Marzan KAB. Diagnosis and management of infectious complications of childhood rheumatic diseases. Curr Rheumatol Rep 2013; 15:322. [PMID: 23443616 DOI: 10.1007/s11926-013-0322-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Progress in the diagnosis and management of pediatric rheumatic disease has improved complications from underlying disease and the survival of children. However, as a consequence, infection has now become one of the leading causes of morbidity and mortality. Differentiating between infections and disease flares in children with rheumatic conditions can often pose diagnostic quandaries. Children with rheumatic diseases are at risk of infection, not only because of the use of immune-modulating medications but also because of underlying immune dysfunction associated with their disease. Although bacterial infections are the most common, any organism can potentially be a causative agent and, at times, more invasive measures of diagnosis, for example bronchoscopy and tissue biopsies may be necessary. Maintaining a high index of suspicion of infection with prompt diagnosis and treatment are important to further improve patient outcomes.
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Affiliation(s)
- Rhina D Castillo
- Children's Hospital Los Angeles, 4650 Sunset Blvd Mailstop 60, Los Angeles, CA 90027, USA.
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Li MC, Lee NY, Lee CC, Lee HC, Chang CM, Ko WC. Pneumocystis jiroveci pneumonia in immunocompromised patients: delayed diagnosis and poor outcomes in non-HIV-infected individuals. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2012; 47:42-7. [PMID: 23063081 DOI: 10.1016/j.jmii.2012.08.024] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 07/17/2012] [Accepted: 08/24/2012] [Indexed: 01/24/2023]
Abstract
BACKGROUND Pneumocystis jiroveci pneumonia (PJP) is a life-threatening disease in immunocompromised patients. Improved knowledge about the varied characteristics and management in different populations may guide treatment. METHODS We evaluated the clinical characteristics, management, and outcomes of patients with PJP diagnosed by nested polymerase chain reaction at a medical center in southern Taiwan from 2008 to 2011. The risk factors of mortality among non-human immunodeficiency virus (HIV)-infected patients were analyzed. RESULTS During the study period, there were 43 cases of PJP, and the common underlying diseases were HIV infection (23 patients, median CD4 count: 19/μl) and malignancy. The HIV-infected patients had a younger age (36.9 ± 13.7 vs. 50.2 ± 16.2 years, p = 0.006), a lower body mass index (19.9 ± 2.3 vs. 22.0 ± 3.7 kg/m(2), p = 0.035), a longer duration of symptoms before admission (24 ± 29 vs. 7 ± 15 days, p = 0.035), and a lower pneumonia severity index (56 ± 25 vs. 99 ± 35, p < 0.001) than non-HIV-infected patients. A delay between admission and starting antimicrobial therapy for PJP (10 ± 10 days vs. 1 ± 3 days, p = 0.004) and a high crude mortality (12/20, 60% vs. 2/23, 9%, p = 0.001) were noted in non-HIV-infected patients. In the univariate analysis, the risk factors for mortality were a low lymphocyte count (p < 0.05) and shock during hospitalization (p = 0.004). CONCLUSION A delay in the initiation of antimicrobial therapy for PJP and severe pneumonia were more common in the non-HIV-infected patients and were most likely related to the poor prognosis. The utilization of sensitive diagnostic tools to facilitate early diagnosis and treatment may improve the clinical outcomes of non-HIV-infected patients with PJP.
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Affiliation(s)
- Ming-Chi Li
- Department of Internal Medicine, National Cheng Kung University, College of Medicine and Hospital, Tainan, Taiwan
| | - Nan-Yao Lee
- Department of Internal Medicine, National Cheng Kung University, College of Medicine and Hospital, Tainan, Taiwan
| | - Ching-Chi Lee
- Department of Internal Medicine, National Cheng Kung University, College of Medicine and Hospital, Tainan, Taiwan
| | - Hsin-Chun Lee
- Department of Internal Medicine, National Cheng Kung University, College of Medicine and Hospital, Tainan, Taiwan
| | - Chia-Ming Chang
- Department of Internal Medicine, National Cheng Kung University, College of Medicine and Hospital, Tainan, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University, College of Medicine and Hospital, Tainan, Taiwan.
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