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Dumas G, Arabi YM, Bartz R, Ranzani O, Scheibe F, Darmon M, Helms J. Diagnosis and management of autoimmune diseases in the ICU. Intensive Care Med 2024; 50:17-35. [PMID: 38112769 DOI: 10.1007/s00134-023-07266-7] [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: 06/23/2023] [Accepted: 11/01/2023] [Indexed: 12/21/2023]
Abstract
Autoimmune diseases encompass a broad spectrum of disorders characterized by disturbed immunoregulation leading to the development of specific autoantibodies, resulting in inflammation and multiple organ involvement. A distinction should be made between connective tissue diseases (mainly systemic lupus erythematosus, systemic scleroderma, inflammatory muscle diseases, and rheumatoid arthritis) and vasculitides (mainly small-vessel vasculitis such as antineutrophil cytoplasmic antibody-associated vasculitis and immune-complex mediated vasculitis). Admission of patients with autoimmune diseases to the intensive care unit (ICU) is often triggered by disease flare-ups, infections, and organ failure and is associated with high mortality rates. Management of these patients is complex, including prompt disease identification, immunosuppressive treatment initiation, and life-sustaining therapies, and requires multi-disciplinary involvement. Data about autoimmune diseases in the ICU are limited and there is a need for multicenter, international collaboration to improve patients' diagnosis, management, and outcomes. The objective of this narrative review is to summarize the epidemiology, clinical features, and selected management of severe systemic autoimmune diseases.
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Affiliation(s)
- Guillaume Dumas
- Medical Intensive Care Unit, Service de Médecine Intensive-Réanimation, CHU Grenoble-Alpes, Université Grenoble-Alpes, INSERM, U1042-HP2, Grenoble, France.
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of the National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences Riyadh, Riyadh, Kingdom of Saudi Arabia
| | - Raquel Bartz
- Department of Anesthesia, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Otavio Ranzani
- Barcelona Institute for Global Health, ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Pulmonary Division, Faculdade de Medicina, Heart Institute, InCor, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Franziska Scheibe
- Department of Neurology and Experimental Neurology, Charité- Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Michaël Darmon
- Medical Intensive Care Unit, APHP, Hôpital Saint-Louis, Famirea Study Group, ECSTRA Team, and Clinical EpidemiologyUMR 1153, Center of Epidemiology and Biostatistics, Sorbonne Paris Cité, CRESS, INSERM, Université Paris Cité, Paris, France
| | - Julie Helms
- Faculté de Médecine, Service de Médecine Intensive-Réanimation, Université de Strasbourg (UNISTRA), Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, 1 Place de L'Hôpital, Strasbourg, France
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Assan F, Bay P, Mathian A, Hekimian G, Bréchot N, Quentric P, Moyon Q, Schmidt M, Cohen-Aubart F, Haroche J, Amoura Z, Luyt CE, Combes A, Pineton de Chambrun M. In-ICU-acquired infections in flare-up systemic rheumatic disease patients receiving immunosuppressant. Clin Rheumatol 2022; 41:2845-2854. [PMID: 35534696 DOI: 10.1007/s10067-022-06197-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/25/2022] [Accepted: 04/30/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Systemic rheumatic diseases (SRDs) are a group of inflammatory disorders that can need intensive care unit (ICU) admission during a flare-up, requiring administration of immunosuppressants. We undertook this study to determine the frequency, outcome, and occurrence associated factors of infections in flare-up SRD patients receiving immunosuppressant. METHODS Monocenter, a retrospective study including SRD patients admitted to ICU for a flare-up requiring immunosuppressant from 2004 to 2019. The primary endpoint was in-ICU-acquired infections. RESULTS Ninety-eight patients (female/male ratio: 1.6; mean age at admission: 39.5 ± 17.4 years) were admitted to the ICU for a SRD flare-up, inaugural in 61.2% cases. A specific treatment was given to every patient: corticosteroids 100%, cyclophosphamide 45.9%, plasma exchange 46.9%. Ninety-five infections occurred in 35 (36%) patients mainly pneumonias. The overall in-hospital mortality was 17.3%, and 46% of patients with a nosocomial infection died during their ICU stay. The logistic regression multivariable model retained renal replacement therapy and mechanical ventilation as independent predictors of infection. CONCLUSION In-ICU-acquired infection in SRD flare-up is a frequent event associated with organ failures but not with in-ICU use of immunosuppressants. These data suggest that the fear of infection should not withhold a careful in-ICU use of immunosuppressive drugs. Key Points • In-ICU infections are frequent in flare-up systemic rheumatic disease patients. • Infections are associated with increased mortality. • Cyclophosphamide given in ICU was not independently associated with infection. • Severe neutropenia occurred in 27% of patients receiving cyclophosphamide in ICU.
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Affiliation(s)
- Florence Assan
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Pierre Bay
- Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France
| | - Alexis Mathian
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Guillaume Hekimian
- Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France
| | - Nicolas Bréchot
- Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France
| | - Paul Quentric
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France.,Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Inserm, Paris, France
| | - Quentin Moyon
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France.,Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France
| | - Matthieu Schmidt
- Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France.,INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, F-75013, Paris, France
| | - Fleur Cohen-Aubart
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Julien Haroche
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Zahir Amoura
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Charles-Edouard Luyt
- Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France.,INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, F-75013, Paris, France
| | - Alain Combes
- Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France.,INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, F-75013, Paris, France
| | - Marc Pineton de Chambrun
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France. .,Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France. .,Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Inserm, Paris, France. .,INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, F-75013, Paris, France.
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