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Asai N, Motojima S, Ohkuni Y, Matsunuma R, Nakashita T, Kaneko N, Mikamo H. Pathophysiological mechanism of non-HIV Pneumocystis jirovecii pneumonia. Respir Investig 2022; 60:522-530. [PMID: 35501264 DOI: 10.1016/j.resinv.2022.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/18/2022] [Accepted: 04/03/2022] [Indexed: 06/14/2023]
Abstract
While Pneumocystis jirovecii pneumonia (PCP) can occur in immunocompromised patients with HIV infection, the prognosis of non-HIV PCP is still poor, showing a high mortality rate of 30%-75%. The pathophysiological mechanism of non-HIV PCP is quite different from that of HIV-PCP. Aging, underlying disease, dysbiotic gut microbiome, and Th1 predominance, leads to macrophagic polarization shifting from M2 to M1. These cause dysregulation in the host immunity against P. jirovecii, resulting in severe lung injury and a high mortality rate among non-HIV PCP patients. This review describes poor prognostic factors, an issue of predictive values used for general pneumonia practice, and new aspects, including the dysbiosis of the gut microbiome and macrophagic polarization in the treatment of non-HIV PCP.
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Affiliation(s)
- Nobuhiro Asai
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Aichi, Japan; Department of Pathology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Shinji Motojima
- Department of Rheumatology & Allergy, Shonan Fujisawa Tokushukai Hospital, Fujisawa, Kanagawa, Japan
| | - Yoshihiro Ohkuni
- Department of Pulmonology, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Ryo Matsunuma
- Department of Pulmonology, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Tamao Nakashita
- Department of Rheumatology & Allergy, Shonan Fujisawa Tokushukai Hospital, Fujisawa, Kanagawa, Japan
| | - Norihiro Kaneko
- Department of Pulmonology, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Hiroshige Mikamo
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Aichi, Japan.
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2
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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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3
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Rutter M, Chakravorty M, Lanyon PC, Courtney P. Pneumocystis jirovecii following rituximab. Rheumatology (Oxford) 2021; 60:iii70-iii72. [PMID: 34137871 DOI: 10.1093/rheumatology/keab040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 01/08/2021] [Indexed: 01/02/2023] Open
Affiliation(s)
- Megan Rutter
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK.,Department of Rheumatology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Mithun Chakravorty
- Department of Rheumatology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Peter C Lanyon
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK.,Department of Rheumatology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Philip Courtney
- Department of Rheumatology, Nottingham University Hospitals NHS Trust, Nottingham, UK
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4
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Iwatani Y, Amemiya N, Nokiba H, Yamazaki M, Sugiura H, Nitta K. Risk factors for cytomegalovirus reactivation in patients with kidney disease under immunosuppressive therapy. Clin Exp Nephrol 2021; 26:22-28. [PMID: 34342776 DOI: 10.1007/s10157-021-02117-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 07/23/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) is a herpes virus that causes latent infections, and its reactivation due to immunosuppression can cause fatal complications. CMV reactivation is a complication frequently occurring in patients with kidney disease who require immunosuppressive therapy, and, therefore, this study retrospectively examined its risk factors. METHODS Patients who received immunosuppressive therapy and underwent the CMV antigenemia test (CMV antigenemia: C7-HRP) for the treatment of primary nephritis (minimal change disease, membranous nephropathy, membranoproliferative glomerulonephritis, focal glomerulosclerosis, and IgA nephropathy) and anti-neutrophil cytoplasmic autoantibody (ANCA)-associated nephritis diagnosed at Saiseikai Kurihashi Hospital from January 2014 to December 2019 were recruited as study participants. Risk factors of CMV reactivation were examined using univariable and multivariable analyses. RESULTS Among the 64 patients (36 men and 28 women; median age, 72 years) included, 34 had primary nephritis (20 minimal disease changes, 10 membranous nephropathy, 1 membranoproliferative glomerulonephritis, 1 focal glomerulosclerosis, and 2 IgA nephropathy) and 30 had ANCA-associated nephritis. Regarding glucocorticoid (GC), 43 patients received oral GC therapy, whereas 21 received GC pulse therapy. CMV reactivation participants showed significant differences in age, ANCA-associated nephritis, hemoglobin level, lymphocyte count, maximum GC dosage, and hemodialysis in univariable analysis. Multivariate analysis showed significantly lower lymphocyte counts in CMV-reactivated patients, but no significant difference in other factors. CONCLUSION In patients with kidney disease, who require immunosuppressive therapy, CMV reactivation risk is high in patients with low lymphocyte count, and monitoring CMV during the treatment course could lead to early diagnosis and treatment of CMV disease.
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Affiliation(s)
- Yosuke Iwatani
- Department of Nephrology, Saitama-ken Saiseikai Kurihashi Hospital, Kuki-shi, Saitama-ken, 349-1105, Japan.
- Department of Nephrology, Tokyo Women's Medical University, Tokyo, 162-0054, Japan.
| | - Nobuyuki Amemiya
- Department of Nephrology, Saitama-ken Saiseikai Kurihashi Hospital, Kuki-shi, Saitama-ken, 349-1105, Japan
- Department of Nephrology, Tokyo Women's Medical University, Tokyo, 162-0054, Japan
| | - Hirohiko Nokiba
- Department of Nephrology, Saitama-ken Saiseikai Kurihashi Hospital, Kuki-shi, Saitama-ken, 349-1105, Japan
- Department of Nephrology, Tokyo Women's Medical University, Tokyo, 162-0054, Japan
| | - Mayuko Yamazaki
- Department of Nephrology, Saitama-ken Saiseikai Kurihashi Hospital, Kuki-shi, Saitama-ken, 349-1105, Japan
- Department of Nephrology, Tokyo Women's Medical University, Tokyo, 162-0054, Japan
| | - Hidekazu Sugiura
- Department of Nephrology, Saitama-ken Saiseikai Kurihashi Hospital, Kuki-shi, Saitama-ken, 349-1105, Japan
- Department of Nephrology, Tokyo Women's Medical University, Tokyo, 162-0054, Japan
| | - Kosaku Nitta
- Department of Nephrology, Tokyo Women's Medical University, Tokyo, 162-0054, Japan
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Raffray L, Guillevin L. Updates for the treatment of EGPA. Presse Med 2020; 49:104036. [PMID: 32652104 DOI: 10.1016/j.lpm.2020.104036] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 05/19/2020] [Accepted: 07/02/2020] [Indexed: 12/17/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA, formerly Churg-Strauss syndrome) is the least frequent antineutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV). Major advances of our knowledge on its pathophysiology have revealed features of both AAV and eosinophilic disorders. The development of targeted biotherapies for both diseases opened new possibilities for EGPA management. In this review, we highlight the rationale underlying the routine treatment strategy, which relies mainly on corticosteroids, with immunosuppressant adjunction for severe disease. However, novel therapies are still needed for refractory/relapsing disease and to alleviate the corticosteroid-dependence of asthma and chronic rhinosinusitis. At present, the most promising biotherapies target either eosinophil biology, like mepolizumab, an anti-interleukin-5, or the B-cell compartment, with rituximab. Recent clinical data on new treatment options are discussed and therapeutic strategies are proposed.
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Affiliation(s)
- Loïc Raffray
- Department of Internal Medicine, Félix-Guyon University Hospital of La Réunion, CS11021, Saint Denis, Reunion
| | - Loïc Guillevin
- Referral Center for Rare Systemic and Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Université Paris Descartes, 27, rue du Faubourg-Saint-Jacques, 75679 Paris Cedex 14, France.
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Cleaton N, Sheeran TP, Ali I. Primary varicella zoster virus resulting in disseminated disease in a patient with granulomatosis with polyangiitis: remain cautious. Rheumatol Adv Pract 2020. [DOI: 10.1093/rap/rkaa051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Natasha Cleaton
- Department of Rheumatology, Royal Wolverhampton Trust, Wolverhampton, UK
| | - Tom P Sheeran
- Department of Rheumatology, Royal Wolverhampton Trust, Wolverhampton, UK
| | - Iman Ali
- Department of Rheumatology, Royal Wolverhampton Trust, Wolverhampton, UK
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7
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Abstract
Pneumocystis jirovecii pneumonia (PcP) has for many years been reported mostly in human immunodeficiency virus-infected patients. Increasingly, it also affects other immunocompromised patients, e.g. after organ or allogeneic stem cell/bone marrow transplantation, patients with hematologic malignancies or autoimmune diseases. The diagnosis of PcP relies on a critical evaluation of clinical symptoms, risk factors, radiologic features and microbiological tests. High dose cotrimoxazole is the most effective therapeutic option. Rapid initiation is essential, since mortality is especially high in patients admitted to intensive care with respiratory failure. This article reviews the current epidemiology of PcP and highlights the diagnostic and therapeutic options. Recommendations for primary and secondary prophylaxis are summarized.
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8
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Raffray L, Guillevin L. Treatment of Eosinophilic Granulomatosis with Polyangiitis: A Review. Drugs 2019; 78:809-821. [PMID: 29766394 DOI: 10.1007/s40265-018-0920-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Eosinophilic granulomatosis with polyangiitis (formerly Churg-Strauss syndrome) is a rare type of anti-neutrophil cytoplasm antibody-associated vasculitis. Nevertheless, eosinophilic granulomatosis with polyangiitis stands apart because it has features of vasculitis and eosinophilic disorders that require targeted therapies somewhat different from those used for other anti-neutrophil cytoplasm antibody-associated vasculitides. Considerable advances have been made in understanding the underlying pathophysiology of eosinophilic granulomatosis with polyangiitis that have highlighted the key role of eosinophils and opened new therapeutic opportunities. Its conventional treatment relies mainly on agents that decrease inflammation: corticosteroids and immunosuppressant adjunction for severe manifestations. New therapeutic approaches are needed for refractory disease, relapses and issues associated with corticosteroid dependence, especially for asthma manifestations. Drugs under evaluation mostly target eosinophils and B cells. Results of low-evidence-based trials suggested possible efficacies of biologicals: B-cell-blocking rituximab and anti-immunoglobulin E omalizumab. Recently, the first large-scale randomised controlled trial on eosinophilic granulomatosis with polyangiitis proved the efficacy of anti-interleukin-5 mepolizumab. That finding opens a new era in eosinophilic granulomatosis with polyangiitis management, with mepolizumab approval but also in future drug evaluations and trial designs for eosinophilic granulomatosis with polyangiitis. Additional studies are needed to determine which patients would benefit most from targeted therapies and achieve personalised treatment for patients with eosinophilic granulomatosis with polyangiitis. Herein, we review eosinophilic granulomatosis with polyangiitis characteristics and provide an overview of established and novel pharmacological agents.
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Affiliation(s)
- Loïc Raffray
- Department of Internal Medicine, Félix-Guyon University Hospital of La Réunion, Saint Denis, Réunion Island, France
| | - Loïc Guillevin
- Department of Internal Medicine, Referral Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Université Paris Descartes, Paris, France.
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9
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Braga BP, Prieto-González S, Hernández-Rodríguez J. Pneumocystis jirovecii pneumonia prophylaxis in immunocompromised patients with systemic autoimmune diseases. Med Clin (Barc) 2019; 152:502-507. [PMID: 30853123 DOI: 10.1016/j.medcli.2019.01.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 02/07/2023]
Abstract
Pneumocystis jirovecii (P. jirovecii) causes a potentially fatal pneumonia in immunocompromised individuals (Pneumocystis pneumonia or PcP), particularly in HIV-infected patients and those treated with immunosuppressive drugs, such as transplant patients and those with systemic autoimmune diseases. P. jirovecii colonization can be found in almost a third of patients with systemic autoimmune diseases. Although the incidence of PcP in such patients is usually low, mortality is quite high, ranging between 30% and 50% in the majority of autoimmune diseases. PcP development is almost always observed in patients not receiving prophylaxis for the infection. Despite the above, there are no clinical guidelines established for PcP prophylaxis in patients with autoimmune diseases treated with glucocorticoids, cytotoxic drugs, or more recently, biological agents. The objective of this review is to analyze the available data on the incidence of PcP and the effect of PcP prophylaxis in patients with autoimmune diseases that may be useful in clinical practice.
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Affiliation(s)
- Beatriz P Braga
- Department of Internal Medicine, Hospital do Divino Espírito Santo de Ponta Delgada, São Miguel, Portugal
| | - Sergio Prieto-González
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - José Hernández-Rodríguez
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.
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10
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Yang L, Xie H, Liu Z, Chen Y, Wang J, Zhang H, Ge Y, Hu W. Risk factors for infectious complications of ANCA-associated vasculitis: a cohort study. BMC Nephrol 2018; 19:138. [PMID: 29902982 PMCID: PMC6002994 DOI: 10.1186/s12882-018-0933-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 05/25/2018] [Indexed: 12/05/2022] Open
Abstract
Background Severe infections are common complications of immunosuppressive treatment for antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) with renal involvement. We investigated the clinical characteristics and risk factors of severe infection in Chinese patients with AAV after immunosuppressive therapy. Methods A total of 248 patients with a new diagnosis of ANCA-associated vasculitis were included in this study. The incidence, time, site, and risk factors of severe infection by the induction therapies were analysed. Multivariate Cox proportional hazards models were used to calculate hazard ratios (HRs) with 95% confidence intervals (CI). Results A total of 103 episodes of severe infection were identified in 86 (34.7%, 86/248) patients during a median follow-up of 15 months. The incidence of infection during induction therapy was 38.5% for corticosteroids (CS), 39.0% for CS+ intravenous cyclophosphamide (IV-CYC), 33.8% for CS+ mycophenolate mofetil and 22.5% for CS + tripterygium glycosides, 76 (73.8%) infection episodes occurred within 6 months, while 66 (64.1%) occurred within 3 months. Pneumonia (71.8%, 74/103) was the most frequent type of infection, and the main pathogenic spectrum included bacteria (78.6%), fungi (12.6%), and viruses (8.7%). The risk factors associated with infection were age at the time of diagnosis (HR = 1.003, 95% CI = 1.000–1.006), smoking (HR = 2.338, 95% CI = 1.236–4.424), baseline secrum creatinine (SCr) ≥5.74 mg/dl (HR = 2.153, 95% CI = 1.323–3.502), CD4+ T cell< 281 μl (HR = 1.813, 95% CI = 1.133–2.900), and intravenous cyclophosphamide regimen (HR = 1.951, 95% CI =1.520–2.740). Twelve (13.9%) patients died of severe pneumonia. Conclusion The infection rate during induction therapy was high in patients with AAV. Bacterial pneumonia was the main type of infection encountered. Age at the time of diagnosis, smoking, baseline SCr ≥5.74 mg/dl, CD4+ T cell< 281 μl, and IV-CYC therapy were identified as risk factors for infection.
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Affiliation(s)
- Liu Yang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, China
| | - Honglang Xie
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, China
| | - Zhengzhao Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, China
| | - Yinghua Chen
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, China
| | - Jinquan Wang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, China
| | - Haitao Zhang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, China
| | - Yongchun Ge
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, China.
| | - Weixin Hu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, China.
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11
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King C, Harper L. Avoidance of Harm From Treatment for ANCA-Associated Vasculitis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2017; 3:230-243. [PMID: 29201630 PMCID: PMC5694500 DOI: 10.1007/s40674-017-0082-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Purpose of review With established immunosuppressant treatment regimens for anti-neutrophil cytoplasm antibody-associated vasculitides (AAV), prognosis has significantly improved. The mainstay of treatment still comprises high-dose corticosteroids and cyclophosphamide for severe forms, although rituximab is being increasingly utilised instead of cyclophosphamide as induction therapy. AAV patients experience an excess of infections, malignancies and cardiovascular events as compared to the general population, which is a combination of the systemic inflammatory process associated with vasculitis and the adverse events from treatment. Recent findings Successful therapy should focus on suppressing disease activity and minimising treatment-related toxicity. Infection is the largest contributor to morbidity and mortality in the first year of treatment, and annual pneumococcal and influenza vaccinations, Pneumocystis jiroveci prophylaxis and tuberculosis (TB) and Hepatitis B virus screening are advised. Patients on high-dose corticosteroid treatment should have regular blood sugar monitoring, a FRAX assessment with vitamin D and calcium supplementation, consideration of prophylaxis for gastric ulcers and a cardiovascular risk assessment. Patients who are treated with cyclophosphamide could also receive MESNA to reduce the risk of chemical cystitis. Cyclophosphamide, methotrexate and azathioprine all require blood monitoring schedules due to the risk of bone marrow suppression, liver and renal toxicity. Hypogammaglobulinaemia is a recognised risk of rituximab treatment. Patients of reproductive age need to be counselled on the infertility risks with cyclophosphamide and the teratogenicity associated with it, methotrexate and mycophenolate mofetil. Summary A greater focus on identifying clinical and biological markers that will help identify those patients at greatest risk of relapse, e.g. GPA and PR3-ANCA specificity, from those patients at greatest risk of toxicity, e.g. increasing age and declining GFR, is required to allow treatment to be tailored accordingly.
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Affiliation(s)
- Catherine King
- Centre for Translational Inflammation Research University of Birmingham Research Laboratories, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB UK
| | - Lorraine Harper
- Centre for Translational Inflammation Research University of Birmingham Research Laboratories, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB UK
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12
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Abstract
Pneumocystis jirovecii pneumonia plays an increasing role in patients with autoimmune disorders, due to more intensive immunosuppressive therapy. Humans seem to be the most important pathogen reservoir. Diseases are probably caused by airborne new infections. Cough, subfebrile temperature and dyspnea on exertion are the leading symptoms. In addition to imaging, in particular high-resolution computed tomography, pathogen detection by staining methods or molecular genetic methods plays the decisive role. Trimethoprim and sulfamethoxazole (TMP-SMX) is the most important medication for treatment. Adjuvant corticosteroid treatment is sometimes recommended, but evidence for benefits in patients with rheumatological disorders is not well documented. For patients on high-dose systemic corticosteroid treatment or intensive combined immunosuppression, primary prophylaxis is recommended by many experts. TMP-SMX remains the first-choice preventive treatment in these patients.
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Affiliation(s)
- S Blaas
- Zentrum für Pneumologie, Klinik Donaustauf, Ludwigstraße 68, 93093, Donaustauf, Deutschland.
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13
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Filocamo G, Torreggiani S, Agostoni C, Esposito S. Lung involvement in childhood onset granulomatosis with polyangiitis. Pediatr Rheumatol Online J 2017; 15:28. [PMID: 28410589 PMCID: PMC5391594 DOI: 10.1186/s12969-017-0150-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 03/20/2017] [Indexed: 12/25/2022] Open
Abstract
Granulomatosis with polyangiitis is an ANCA-associated systemic vasculitis with a low incidence in the pediatric population. Lung involvement is a common manifestation in children affected by granulomatosis with polyangiitis, both at disease's onset and during flares. Its severity is variable, ranging from asymptomatic pulmonary lesions to dramatic life-threatening clinical presentations such as diffuse alveolar haemorrhage. Several radiologic findings have been described, but the most frequent abnormalities detected are nodular lesions and fixed infiltrates. Interstitial involvement, pleural disease and pulmonary embolism are less common. Histology may show necrotizing or granulomatous vasculitis of small arteries and veins of the lung, but since typical features may be patchy, the site for lung biopsy should be carefully chosen with the help of imaging techniques such as computed tomography. Bronchoalveolar lavage is helpful to confirm the diagnosis of alveolar haemorrhage. Pulmonary function tests are frequently altered, showing a reduction in the diffusion capacity for carbon monoxide, which can be associated with obstructive abnormalities related to airway stenosis. Nodular lung lesions tend to regress with immunosuppressive therapy, but lung disease may also require second line treatments such as plasmapheresis. In cases of massive diffuse alveolar haemorrhage, ventilator support is crucial in the management of the patient.
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Affiliation(s)
- Giovanni Filocamo
- Pediatric Rheumatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via Commenda 9, 20122, Milan, Italy.
| | - Sofia Torreggiani
- grid.4708.bFondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Carlo Agostoni
- grid.4708.bFondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Susanna Esposito
- grid.9027.cPediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
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14
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Lazarus B, John GT, O'Callaghan C, Ranganathan D. Recent advances in anti-neutrophil cytoplasmic antibody-associated vasculitis. Indian J Nephrol 2016; 26:86-96. [PMID: 27051131 PMCID: PMC4795442 DOI: 10.4103/0971-4065.171225] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Anti-neutrophil cytoplasmic antibody-associated vasculitis is an uncommon inflammatory disease of small to medium-sized vessels that frequently presents with rapidly progressive glomerulonephritis and renal failure though it can affect any organ system. If untreated, the vast majority of patients will die within a year. Current treatments improve prognosis but affected patients remain at a substantially higher risk of death and adverse outcomes. We review the classification of the disease, our understanding of the pathogenesis and epidemiology, and propose future directions for research. We also evaluate the evidence supporting established treatment regimens and the progress of clinical trials for newer treatments to inform the design of future studies.
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Affiliation(s)
- B Lazarus
- Department of Kidney Health Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - G T John
- Department of Kidney Health Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - C O'Callaghan
- Department of Kidney Health Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - D Ranganathan
- Department of Kidney Health Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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Dumas G, Géri G, Montlahuc C, Chemam S, Dangers L, Pichereau C, Brechot N, Duprey M, Mayaux J, Schenck M, Boisramé-Helms J, Thomas G, Baboi L, Mouthon L, Amoura Z, Papo T, Mahr A, Chevret S, Chiche JD, Azoulay E. Outcomes in critically ill patients with systemic rheumatic disease: a multicenter study. Chest 2016; 148:927-935. [PMID: 25996557 DOI: 10.1378/chest.14-3098] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Patients with systemic rheumatic diseases (SRDs) may require ICU management for SRD exacerbation or treatment-related infections or toxicities. METHODS This was an observational study at 10 university-affiliated ICUs in France. Consecutive patients with SRDs were included. Determinants of ICU mortality were identified through multivariable logistic analysis. RESULTS Three hundred sixty-three patients (65.3% women; median age, 59 years [interquartile range, 42-70 years]) accounted for 381 admissions. Connective tissue disease (primarily systemic lupus erythematosus) accounted for 66.1% of SRDs and systemic vasculitides for 26.2% (chiefly antineutrophil cytoplasm antibodies-associated vasculitides). SRDs were newly diagnosed in 43 cases (11.3%). Direct admission to the ICU occurred in 143 cases (37.9%). Reasons for ICU admissions were infection (39.9%), SRD exacerbation (34.4%), toxicity (5.8%), or miscellaneous (19.9%). Respiratory involvement was the leading cause of admission (56.8%), followed by shock (41.5%) and acute kidney injury (42.2%). Median Sequential Organ Failure Assessment (SOFA) score on day 1 was 5 (3-8). Mechanical ventilation was required in 57% of cases, vasopressors in 33.9%, and renal replacement therapy in 28.1%. ICU mortality rate was 21.0% (80 deaths). Factors associated with ICU mortality were shock (OR, 3.77; 95% CI, 1.93-7.36), SOFA score at day 1 (OR, 1.19; 95% CI, 1.10-1.30), and direct admission (OR, 0.52; 95% CI, 0.28-0.97). Neither comorbidities nor SRD characteristics were associated with survival. CONCLUSIONS In patients with SRDs, critical care management is mostly needed only in patients with a previously known SRD; however, diagnosis can be made in the ICU for 12% of patients. Infection and SRD exacerbation account for more than two-thirds of these situations, both targeting chiefly the lungs. Direct admission to the ICU may improve outcomes.
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Affiliation(s)
- Guillaume Dumas
- Medical Intensive Care Unit, Saint-Louis Teaching Hospital, Paris
| | - Guillaume Géri
- Medical Intensive Care Unit, Cochin Teaching Hospital, Paris
| | | | - Sarah Chemam
- Medical Intensive Care Unit, Bichat Hospital, Paris
| | - Laurence Dangers
- Service de réanimation médicale, Institut de Cardiologie, Pitié-Salpêtrière Teaching Hospital, Paris
| | | | - Nicolas Brechot
- Service de réanimation médicale, Institut de Cardiologie, Pitié-Salpêtrière Teaching Hospital, Paris
| | - Matthieu Duprey
- Service de réanimation médicale, Institut de Cardiologie, Pitié-Salpêtrière Teaching Hospital, Paris
| | - Julien Mayaux
- Medical Intensive Care Unit, Pitié-Salpêtrière Teaching Hospital, Paris
| | - Maleka Schenck
- Medical Intensive Care Unit, Hautepierre Teaching Hospital, Strasbourg
| | - Julie Boisramé-Helms
- Medical Intensive Care Unit, Nouvel Hôpital Civil, Strasbourg Teaching Hospital, Strasbourg
| | - Guillemette Thomas
- Assistance-Publique-Hôpitaux de Marseille, Hôpital Nord, Réanimation des Détresses respiratoires et des Infections Sévères, Marseille
| | | | - Luc Mouthon
- Université Paris-Descartes, Department of Internal Medicine, Cochin Teaching Hospital, Paris, France
| | - Zair Amoura
- Department of Internal Medicine, Pitié-Salpêtrière Teaching Hospital, Paris
| | - Thomas Papo
- Assistance-Publique-Hôpitaux de Marseille, Hôpital Nord, Réanimation des Détresses respiratoires et des Infections Sévères, Marseille; Department of Internal Medicine, Bichat Hospital, Paris
| | - Alfred Mahr
- Department of Internal Medicine, Saint-Louis Teaching Hospital, Paris
| | - Sylvie Chevret
- Biostatistics Department, Saint-Louis Teaching Hospital, Paris
| | | | - Elie Azoulay
- Medical Intensive Care Unit, Saint-Louis Teaching Hospital, Paris.
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Abstract
BACKGROUND Recent data from randomized controlled clinical trials have allowed the development of recommendations for treatment of anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitides (AAV). METHODS A selective literature search was carried out for studies and recommendations for treatment of AAV. RESULTS In active severe AAV a combination of prednisolone and cyclophosphamide or rituximab leads to a therapeutic response in approximately 90 % of cases. Once remission is attained the administration of azathioprine or methotrexate for 2-4 years is required for maintenance of remission. Relapse occurs in more than 30 % of patients despite maintenance treatment. In cases of persistence or progression of disease activity during standard therapy, referral to an expert center should be considered. Despite improvement in the prognosis in recent years early mortality is increased, particularly due to infections. CONCLUSION Stage and activity adapted treatment strategies have improved the outcome of AAV in the past three decades. The elevated early mortality and the risk of relapse show the need for further improvement of current treatment protocols with respect to substance selection, dosage of glucocorticoids and immunosuppressants and the duration of therapy.
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Affiliation(s)
- Uwe Wollina
- Department of Dermatology and Allergology, Academic Teaching Hospital Dresden-Friedrichstadt, Dresden, Germany.
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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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19
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Abstract
The antineutrophil cytoplasmic antibody (ANCA)-associated systemic vasculitides (AASVs) include granulomatosis with polyangiitis and microscopic polyangiitis. These conditions are characterized by small-vessel inflammation and necrosis, predominantly in pulmonary and renal vascular beds. Untreated AASV has a poor prognosis, although the advent of effective immunosuppressive therapy (the mainstay of which remains cyclophosphamide with high-dose corticosteroids) has markedly improved patients' survival (78% at 5 years). Patients with AASV, however, continue to have an increased mortality compared to the general population. Mortality is greatest in the first year after diagnosis and remains consistently elevated in subsequent years. Patients with AASV also experience increased rates of infections, malignancies and cardiovascular events as compared to the general population. Current treatments for AASV, although effective in controlling the aggressive systemic disease, incur substantial long-term toxic effects. Long-term immunosuppressive therapy also has notable deleterious effects on bone health and fertility. The long-term safety profiles of biological therapies (such as rituximab) are yet to be evaluated in patients with AASV, but represent a promising treatment option. The challenge for the future is to develop specific therapies with improved safety profiles that can cure these diseases.
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21
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Shobha V. Common anti-infective prophylaxis and vaccinations in autoimmune inflammatory rheumatic diseases. INDIAN JOURNAL OF RHEUMATOLOGY 2012. [DOI: 10.1016/s0973-3698(12)60005-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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22
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Stilling-Vinther MK, Pedersen BS. Fatal Pneumocystis jirovecii pneumonia following immunosuppressive therapy with rituximab and prednisolone for posterior scleritis. Acta Ophthalmol 2012; 90:e154-5. [PMID: 21649871 DOI: 10.1111/j.1755-3768.2011.02127.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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23
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Abstract
The outcome of ANCA (antineutrophil cytoplasmic antibody)-associated vasculitis (AAV) has been significantly improved due to the combined use of cyclophosphamide (CYC) and glucocorticosteroids. Recent studies demonstrated a normalization of life expectancy for several subgroups of AAV patients. Mortality is highest in the first year after diagnosis and infections are the most frequent cause of death. Older age and renal failure are associated with worse outcome. The use of Pneumocystis jiroveci prophylaxis and subsequent activity-adapted GC dose reduction (target: below 10 mg per day) can substantially reduce the risk of severe infections. Late sequelae of CYC medication, such as cystitis and malignancy should be recognized and can be minimized by the usage of uroprotection with mesna and avoidance of high cumulative CYC doses.
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Schmidt J, Warrington KJ. Polymyalgia rheumatica and giant cell arteritis in older patients: diagnosis and pharmacological management. Drugs Aging 2012; 28:651-66. [PMID: 21812500 DOI: 10.2165/11592500-000000000-00000] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Giant cell arteritis (GCA) is an inflammatory vasculopathy that involves large- and medium-sized arteries and can cause vision loss, stroke and aneurysms. GCA occurs in people aged >50 years and is more common in women. A higher incidence of the disease is observed in populations from Northern European countries. Polymyalgia rheumatica (PMR) is a periarticular inflammatory process manifesting as pain and stiffness in the neck, shoulders and pelvic girdle. PMR shares the same pattern of age and sex distribution as GCA. The pathophysiology of PMR and GCA is not completely understood, but the two conditions may be related and often occur concurrently. A delay in the diagnosis should be avoided because of the risk of vascular ischaemic complications due to GCA. The diagnosis should be considered in patients aged >50 years presenting with symptoms such as new headache, visual disturbances, jaw claudication or symptoms of PMR. GCA can also present as a systemic inflammatory syndrome with fever of unknown origin. Marked elevation of acute-phase reactants, recognizable in higher erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels, is often seen in both PMR and GCA. However, some patients can present with a normal ESR. Confirmation of the diagnosis of GCA by temporal artery biopsy is important because clinical findings and laboratory tests are not specific, and because a diagnosis of GCA commits patients to long-term treatment with corticosteroids. The role of imaging techniques for the diagnosis of GCA remains unclear, but these modalities can be helpful in assessing the extent of vascular involvement, especially when extra-cranial disease is present. In PMR, subdeltoid and subacromial bursitis can be identified by imaging techniques, especially ultrasound or MRI. The clinical manifestations of GCA and PMR respond dramatically within 12-48 hours of starting corticosteroid treatment. The initial corticosteroid dosage commonly used in GCA is oral prednisone 40-60 mg/day, and for patients with PMR a dosage of 15-20 mg/day is often sufficient. A prolonged course of treatment is necessary, and corticosteroids are gradually tapered, guided by regular clinical evaluation and ESR (and/or CRP) measurement. Methotrexate is the best studied corticosteroid-sparing agent in GCA, and may be useful for patients with frequent disease relapses and/or corticosteroid-related toxicity. Retrospective studies favour aspirin (acetylsalicylic acid) as an effective adjuvant treatment for reducing the ischaemic complications of GCA. The long-term course of corticosteroid therapy frequently exposes elderly patients with PMR/GCA to various adverse effects, which can be attenuated with appropriate prophylactic measures. Co-morbid diseases and polypharmacy can pose particular challenges in the geriatric population. In general, the life expectancy of patients with GCA does not appear to be shortened, whereas the morbidity associated with the disease and its treatment is well recognized.
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Affiliation(s)
- Jean Schmidt
- Department of Internal Medicine and RECIF, Amiens University Hospital, France
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25
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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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27
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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: 127] [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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