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Ongarj J, Intapiboon P, Surasombatpattana S, Satti I, Harris SA, Morrison H, Sophonmanee R, McShane H, Tanner R, Pinpathomrat N. Evaluation of immune profiles associated with control of mycobacterial growth in systemic lupus erythematosus (SLE) patients. Tuberculosis (Edinb) 2024; 148:102533. [PMID: 38878478 DOI: 10.1016/j.tube.2024.102533] [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: 04/07/2024] [Revised: 06/10/2024] [Accepted: 06/13/2024] [Indexed: 09/09/2024]
Abstract
Tuberculosis (TB) is an infectious disease with the burden concentrated in low- and middle-income countries. Systemic lupus erythematosus (SLE) is an autoimmune disease associated with widespread inflammation that is prevalent in some TB endemic areas including East Africa and parts of Southeast Asia. SLE patients are known to be at higher risk of becoming infected with M. tb, developing TB disease. However, the immune mechanisms underlying this susceptibility are not well understood, particularly in the absence of immunosuppressive drugs. We present a pilot study in which we have evaluated intracellular cytokine responses and ex vivo ability to control mycobacterial growth using peripheral blood mononuclear cells (PBMC) collected from SLE patients before and during SLE treatment. After six months of treatment, SLE patients had the highest frequencies of CD8+ T cells, NK cells and NKT cells producing IFN-γ and/or TNF-α. This group also showed superior control of mycobacterial growth, and proinflammatory cytokine-producing NK and NKT cells correlated with mycobacterial growth inhibition at the individual patient level. These findings contribute to a better understanding of autoimmune profiles associated with control of mycobacterial growth in SLE patients, which may inform intervention strategies to reduce risk of TB disease in this population.
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Affiliation(s)
- Jomkwan Ongarj
- Department of Biomedical Sciences and Biomedical Engineering, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Porntip Intapiboon
- Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | | | - Iman Satti
- The Jenner Institute, University of Oxford, Oxford, United Kingdom
| | | | - Hazel Morrison
- The Jenner Institute, University of Oxford, Oxford, United Kingdom
| | - Ratchanon Sophonmanee
- Department of Biomedical Sciences and Biomedical Engineering, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Helen McShane
- The Jenner Institute, University of Oxford, Oxford, United Kingdom
| | - Rachel Tanner
- Department of Biology, University of Oxford, Oxford, United Kingdom
| | - Nawamin Pinpathomrat
- Department of Biomedical Sciences and Biomedical Engineering, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand.
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Chatterjee R, Pattanaik SS, Misra DP, Agarwal V, Lawrence A, Misra R, Aggarwal A. Tuberculosis remains a leading contributor to morbidity due to serious infections in Indian patients of SLE. Clin Rheumatol 2023:10.1007/s10067-023-06592-x. [PMID: 37040053 PMCID: PMC10088612 DOI: 10.1007/s10067-023-06592-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 03/29/2023] [Accepted: 04/02/2023] [Indexed: 04/12/2023]
Abstract
INTRODUCTION Infections are a major cause of morbidity and mortality in systemic lupus erythematosus (SLE). We assessed the incidence and risk factors for major infections in SLE in India. METHODS A retrospective review of a cohort of 1354 patients of adult SLE (ACR 1997 criteria) seen between 2000 and 2021 at a single center was conducted. Serious infections (need for hospitalisation, prolonged intravenous antibiotics, disability, or death) were recorded. Cox regression was used to determine factors associated with serious infection and the effects of serious infection on survival and damage. RESULTS Among the 1354 patients (1258 females, mean age of 30.3 years, follow-up of 7127.89 person-years), there were 439 serious infections in 339 patients (61.6 per 1000 person-years follow-up). Bacterial infections (N = 226) were the most common infection followed by mycobacterial infections (n = 81), viral (n = 35), and then invasive fungal infections (N = 13). Mycobacterium tuberculosis was the single most common microbiologically confirmed organism with incidence of 1136.4/100,000 person-years with 72.8% of them being extrapulmonary. Infection free survival at 1 year and 5 years was 82.9% and 73.8%. There were 119 deaths with infection attributable mortality in 65 (54.6%). On multivariable Cox regression analysis, higher baseline activity (HR 1.02, 1.01-1.05), gastrointestinal involvement (HR 2.75, 1.65-4.69), current steroid dose (HR 1.65, 1.55-1.76), and average cumulative steroid dose per year (HR 1.007, 1.005-1.009) were associated with serious infection and higher albumin (HR 0.65, 0.56-0.76) was protective. Serious infections led to greater damage accrual (median SLICC damage index of 1 vs. 0) and mortality (HR was 18.2, 32.7 and 81.6 for the first, second, and third infections). CONCLUSION Serious infections remain a major cause of mortality and damage accrual in SLE and higher disease activity, gastrointestinal involvement, hypoalbuminemia, current steroid dose, and cumulative steroid dose are the risk factors for it.
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Affiliation(s)
- Rudrarpan Chatterjee
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sarit Sekhar Pattanaik
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Durga P Misra
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Vikas Agarwal
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Able Lawrence
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Ramnath Misra
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Amita Aggarwal
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
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A Case of Previously Undiagnosed Systemic Lupus Erythematosus and Mycobacterium tuberculosis Infection Presenting as Diffuse Alveolar Hemorrhage. Case Rep Rheumatol 2023; 2023:3686772. [PMID: 36686202 PMCID: PMC9848806 DOI: 10.1155/2023/3686772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/30/2022] [Accepted: 12/07/2022] [Indexed: 01/13/2023] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is described as the collection of blood in alveolar spaces caused by damaged pulmonary vasculature. It often presents as a life-threatening medical emergency that requires urgent medical intervention along with timely diagnosis and management of the underlying cause. We hereby report a 19-year-old female who presented with clinical and radiological characteristics consistent with DAH. Laboratory workup studies revealed a diagnosis of systemic lupus erythematosus (SLE) as well as Mycobacterium tuberculosis (MTB) infection. This report describes an extremely unusual case of undiagnosed SLE and coexistent tuberculosis presenting as DAH. This leads to an interesting possibility of risks in patients with immune-mediated vasculitis towards developing severe pulmonary disease in the setting of pulmonary mycobacterial infection.
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Al-arbi KMS, Magula NP, Mody GM. Tuberculosis remains a major burden in systemic lupus erythematosus patients in Durban, South Africa. Front Med (Lausanne) 2023; 10:1118390. [PMID: 36936236 PMCID: PMC10014752 DOI: 10.3389/fmed.2023.1118390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/07/2023] [Indexed: 03/05/2023] Open
Abstract
Objective Infections are common in systemic lupus erythematosus (SLE), with tuberculosis (TB) being important in an endemic environment. We studied the prevalence and spectrum of TB in SLE in Durban, South Africa. Methods A medical records review of SLE patients seen over 13-year period, and the demographic data, clinical manifestations, laboratory findings, treatment and outcome were noted. Results There were 512 SLE patients and 72 (14.1%) had TB. Thirty (41.7%) had pulmonary TB (PTB) and 42 (58.3%) had extra-pulmonary TB (EPTB). The prevalence of TB among the different ethnic groups was 36/282 (12.8%) for Indian people, 29/184 (15.8%) Black African people, 7/26 (26.9%) admixed African people and none among the 18 White people. Comparison of the 72 SLE-TB patients with 72 SLE controls showed no difference in gender, age at SLE diagnosis and disease duration. The SLE-TB patients had a significant increase in the clinical and laboratory features of disease activity (arthritis, mucocutaneous lesions, renal involvement, vasculitis, low complement, raised ds-DNA antibodies), and cumulative prednisone use over the preceding 3 months.Compared to PTB, the EPTB patients were significantly younger, developed TB earlier after SLE diagnosis, and had higher disease activity. The EPTB patients also had increase in features of disease activity (renal, thrombocytopenia, ds-DNA antibodies), and increase in ever use of intravenous methylprednisolone (IV-MP) and mycophenolate mofetil (MMF). On multivariate analysis, the independent risk factors for EPTB were ever use of MMF (p = 0.003) and IV-MP (p = 0.027). Analysis of the cumulative SLE criteria showed renal involvement was an independent risk factor for EPTB. The outcome was similar in both groups. Conclusion We show an increased prevalence of TB (14.1%) and EPTB (58.3%) in SLE in an endemic area and confirm that features of disease activity and use of immunosuppressive therapy are the major risk factors. Renal involvement (as a cumulative criterion) is an independent risk factor for EPTB.
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Affiliation(s)
- Khaled Mohamed Sefow Al-arbi
- Department of Rheumatology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal and Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Nombulelo P. Magula
- Division of Internal Medicine, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Girish M. Mody
- Department of Rheumatology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal and Inkosi Albert Luthuli Central Hospital, Durban, South Africa
- *Correspondence: Girish M. Mody,
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Wu P, Zeng J, Yang L. Case Report: Vesicorectal Fistula Caused by Intestinal Tuberculosis Complicated with Systemic Lupus Erythematosus. Infect Drug Resist 2022; 15:6237-6243. [PMID: 36324670 PMCID: PMC9621025 DOI: 10.2147/idr.s383893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/19/2022] [Indexed: 11/05/2022] Open
Abstract
Patients with systemic lupus erythematosus (SLE) are prone to various infections due to autoimmune defects and long-term use of immunosuppressive agents. Mycobacterium tuberculosis (TBC) infection is a common infection in patients with SLE, especially in developing countries such as China. SLE and TBC may overlap and confuse a clinical picture, bringing great difficulties for the diagnosis and treatment. This article reports a case of vesicorectal fistula caused by intestinal TBC complicated with SLE, where the manifestation was recurrent diarrhea, initially treated as lupus-associated intestinal vasculitis without notable response. This case suggests that we should pay attention to close monitoring of tuberculosis-related indicators during the follow-up period of SLE patients, especially in endemic areas, and early diagnosis and treatment of TBC can reduce tuberculosis-related complications and significantly improve the quality of life of patients.
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Affiliation(s)
- Pengjia Wu
- Department of Rheumatology and Immunology, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550000, People’s Republic of China
| | - Jiashun Zeng
- Department of Rheumatology and Immunology, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550000, People’s Republic of China,Correspondence: Jiashun Zeng, Email
| | - Lei Yang
- Department of Rheumatology and Immunology, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550000, People’s Republic of China
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Wu Q, Liu Y, Wang W, Zhang Y, Liu K, Chen SH, Chen B. Incidence and prevalence of tuberculosis in systemic lupus erythematosus patients: A systematic review and meta-analysis. Front Immunol 2022; 13:938406. [PMID: 35935948 PMCID: PMC9355093 DOI: 10.3389/fimmu.2022.938406] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 06/30/2022] [Indexed: 11/23/2022] Open
Abstract
Background Systemic lupus erythematosus (SLE) patients are particularly susceptible to infections, such as pulmonary tuberculosis (PTB) and extrapulmonary tuberculosis (EPTB). This meta-analysis aimed to determine the incidence and prevalence of tuberculosis (TB) in SLE patients. Methods The Web of Science, PubMed, Cochrane Library, and Chinese National Knowledge Infrastructure databases were searched for articles of relevant studies published from the dates the databases were established until April 30, 2022. The I2 statistic and Q test were used to evaluate heterogeneity among the analysed studies. Random-effects models were utilised and subgroup analyses were conducted for analysis of the study data. Results A total of 35 studies with 46,327 SLE patients were eligible for analysis. The incidence and prevalence of TB among the SLE patients were 1.16 per 100 person-years (95% confidence interval (CI): 0.69-1.93) and 3.59% (95% CI: 2.57%-5.02%), respectively. The pooled prevalence of SLE-PTB and SLE-EPTB was 2.46% (95% CI: 1.73%-3.51%) and 1.42% (95% CI: 0.98%-2.06%), respectively. Subgroup analyses showed that the incidence of SLE-TB was higher in Africa and in countries with a high TB burden than in countries with a low TB burden. The prevalence of SLE-TB was elevated in Asia, in patients taking a mean daily dose of glucocorticoids ≥20 mg, in studies with small sample sizes (n <1000) and ended before 2001. Conclusions The available evidence suggests that both the incidence and prevalence of TB in SLE patients are high. This study provides a more specific understanding of SLE-TB, which can help health policymakers in the development of preventive strategies for reducing the SLE-TB burden.
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Affiliation(s)
- Qian Wu
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
| | - Yang Liu
- Department of Infectious Diseases Control and Prevention, Jiaxing Center for Disease Control and Prevention, Jiaxing, China
| | - Wei Wang
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
| | - Yu Zhang
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
| | - Kui Liu
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
| | - Song-Hua Chen
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
| | - Bin Chen
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
- *Correspondence: Bin Chen,
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Hamijoyo L, Sahiratmadja E, Ghassani NG, Darmawan G, Susandi E, van Crevel R, Hill PC, Alisjahbana B. Tuberculosis among Patients with Systemic Lupus Erythematosus in Indonesia: a Cohort study. Open Forum Infect Dis 2022; 9:ofac201. [PMID: 35794932 PMCID: PMC9251660 DOI: 10.1093/ofid/ofac201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/10/2022] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
Previous studies have identified systemic lupus erythematosus (SLE) as a risk factor for tuberculosis (TB), but data from TB endemic countries are still relatively scarce. We examined TB in a large cohort of SLE patients in Indonesia.
Methods
All patients registered in a lupus registry of the top-referral hospital for West-Java between 2008 and 2020 were included. Data on SLE characteristics and treatment were retrieved from the registry, and data on TB diagnosis, localization and outcome were extracted from medical records. Cox-proportional hazard model was used to examine risk factors for development of TB.
Results
Among 1278 SLE patients followed over a total of 4804 patient years, 131 patients experienced 138 episodes of TB, a median 2 years (IQR 0.6–5.4) after diagnosis of SLE. A total of 113 patients (81.9%) had pulmonary and 61 (44.2%) had extra-pulmonary involvement, with disseminated disease in 26 of 138 episodes (18.8%), and 13 of 131 patients (9.9%) died from TB. The estimated TB incidence was 2,873 cases per 100,000 person years. In multivariate cox regression analysis, development of TB was associated with household TB contact (HR 7.20; 95%CI 4.05-12.80), pulse methylprednisolone therapy (HR 1.64; 95%CI 1.01-2.67) and age ≤ 25 years old at SLE diagnosis (HR 1.54; 95%CI 1.00-2.35).
Conclusion
There is a high burden of TB in SLE patients in this TB endemic setting, underlining the need for evaluation or implementation of TB preventive strategies.
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Affiliation(s)
- Laniyati Hamijoyo
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran / Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
- Study Center of Immunology, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Edhyana Sahiratmadja
- Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
- Research Center for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia
| | - Nadia G. Ghassani
- Study Center of Immunology, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Guntur Darmawan
- Department of Internal Medicine, Faculty of Medicine, Krida Wacana Christian University, Jakarta, Indonesia
| | - Evan Susandi
- Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Reinout van Crevel
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Philip C. Hill
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Bachti Alisjahbana
- Research Center for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia
- Division of Tropical Diseases, Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran / Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
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Molooghi K, Sheybani F, Naderi H, Mirfeizi Z, Morovatdar N, Baradaran A. Central nervous system infections in patients with systemic lupus erythematosus: a systematic review and meta-analysis. Lupus Sci Med 2022; 9:9/1/e000560. [PMID: 34980679 PMCID: PMC8724813 DOI: 10.1136/lupus-2021-000560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 12/09/2021] [Indexed: 11/17/2022]
Abstract
We aimed to conduct a systematic review and meta-analysis of studies on central nervous system (CNS) infections in patients with SLE, in order to describe their clinical and microbiological characteristics, and outcomes. A systematic search of PubMed/Medline and Embase electronic databases was performed (March 2021) to identify all published studies on CNS infections and their characteristics in patients with SLE. A random-effects model was adopted and findings were reported with 95% CI. Overall, 6 studies involving 17 751 patients with SLE and 209 SLE cases with CNS infection were included in our meta-analysis. The frequency rate of CNS infections in patients with SLE was 0.012 (95% CI: 0.008 to 0.018). Meningitis was the most common clinical syndrome (93.5%, n=109/114, 95% CI: 82.6% to 97.8%) and Cryptococcus neoformans (35.9%, n=55, 95% CI: 27.2% to 45.7%) and Mycobacterium tuberculosis (27.1%, n=43, 95% CI: 14.6% to 44.8%) were the most common causative pathogens. Our patient-pool showed a mean SLE Disease Activity Index (SLEDAI) score of 7.9 (95% CI: 6.1 to 9.6), while 92.4% (n=72/76, 95% CI: 83.0% to 96.8%) of cases were on oral systemic corticosteroids, with a prednisone equivalent mean daily dose of 30.9 mg/day (95% CI: 18.0 to 43.7). Our meta-analysis revealed a mortality rate of 29.0% (95% CI: 15.0% to 48.6%). Clinicians should maintain a high index of suspicion for cryptococcal and tuberculosis (TB) meningitis in patients with SLE with suspected CNS infection, particularly in those with higher SLEDAI and on higher doses of systemic corticosteroids. In conclusion, initiation of empiric antituberculous treatment for patients with SLE who are highly suspected to have CNS TB is warranted while awaiting the results of diagnostic tests. Antifungals might also be potentially useful empirically in patients with SLE who are suspected to have fungal CNS infections. However, with respect to side effects such as toxicity and high cost of antifungals, decision regarding early antifungal therapy should be guided by early and less time-consuming fungal diagnostic tests.
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Affiliation(s)
- Kasra Molooghi
- Department of Infectious Diseases and Tropical Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fereshte Sheybani
- Department of Infectious Diseases and Tropical Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hamidreza Naderi
- Department of Infectious Diseases and Tropical Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Zahra Mirfeizi
- Rheumatic Diseases Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Negar Morovatdar
- Clinical Research Unit, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ashkan Baradaran
- Department of Infectious Diseases and Tropical Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Consani Fernández SA, Díaz Cuña CL, Fernández Rey L, Rostán Sellanes S, Maciel Oleggini G, Facal Castro JA. Infections in systemic autoimmune diseases. REUMATOLOGIA CLINICA 2021; 17:582-587. [PMID: 34823825 DOI: 10.1016/j.reumae.2020.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 06/30/2020] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Infections are a major cause of morbidity and mortality in patients with systemic autoimmune diseases. The aim of the present study is to describe the frequency of infections in a historical cohort of the SAD polyclinic of the Maciel Hospital, according to the type of disease and treatment received. MATERIAL AND METHODS An analytical, retrospective and observational study was conducted in 339 patients with SAD attended at the outpatient clinic in the period from January 1, 2012 to February 28, 2019. Infectious complications were analysed according to treatment and disease. RESULTS 339 cases, median age 56, mostly female. Most cases presented SLE (30.1%) and RA (23.6%), followed by antiphospholipid syndrome (20.4%) and Sjögren's syndrome (12.1%). Hydroxychloroquine (66%), followed by corticosteroids (55.5%) were the most frequently used treatments. Thirteen point three percent received biological therapies: 46.9% of the cases presented some infectious complication, 95% were non-opportunistic. Respiratory infections were the most frequent (48.6%) followed by urinary infections (31.7%) and skin and soft tissue infections (17.6%). On comparing the infected and non-infected groups, significant differences were found in the following variables: methotrexate, mycophenolate, corticoids, biological therapies, combination of drugs, active disease, RA and cases with overlap. The use of hydroxychloroquine and sulfasalazine was associated with a lower risk of infection in patients with RA. CONCLUSIONS Infections are a frequent complication in patients with RA, due to the immune disturbances of the disease itself and prescribed treatments, mainly corticoids and biologicals. The importance of screening and infection prophylaxis before starting treatment is stressed.
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Affiliation(s)
| | - Carolina Laura Díaz Cuña
- Asistente de Clínica Médica «3», Hospital Maciel, Udelar, Asistente del Departamento Básico de Medicina, Montevideo, Uruguay
| | - Lucia Fernández Rey
- Asistente de Clínica Médica «3», Hospital Maciel, Udelar, Montevideo, Uruguay
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Muhammed H, Jain A, Pattanaik SS, Chatterjee R, Naveen R, Kabeer H, Gupta L, Misra DP, Agarwal V, Lawrence A, Misra R, Aggarwal A. Clinical spectrum of active tuberculosis in patients with systemic lupus erythematosus. Rheumatol Int 2021; 41:2185-2193. [PMID: 34191047 DOI: 10.1007/s00296-021-04933-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 06/20/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION There is paucity of data on tuberculosis in Indian patients with systemic lupus erythematosus (SLE). We retrospectively studied clinical features and outcome of tuberculosis in SLE. METHODS Medical records of patients who developed tuberculosis simultaneous or after the diagnosis of SLE were retrospectively reviewed. All patients fulfilled 1997 ACR and/or SLICC 2012 classification criteria for SLE. A diagnosis of tuberculosis required bacteriological, histopathological or CT/MRI suggestive of tuberculosis and initiation of four drug antituberculous therapy. Baseline parameters were compared with the rest of cohort to identify predictors of tuberculosis. RESULTS In our cohort of 1335 SLE patients, 48 (3.6%) developed tuberculosis. Incidence of tuberculosis was calculated to be 733 per 100,000 patient years and occurred after a mean disease duration of 3.0 ± 4.1 years. Extrapulmonary tuberculosis (n = 37) was commoner than pulmonary tuberculosis (n =11). Most common radiological pattern in pulmonary tuberculosis was miliary and musculoskeletal TB was most common extrapulmonary TB. A microbiological diagnosis was obtained in 52.1% patients. Male gender was associated with higher risk of tuberculosis [OR 3.30 (1.55-7.05)]. Mortality was 14.5% and all patients who died had either disseminated (n = 5) or central nervous system (CNS) tuberculosis (n = 2). CONCLUSION Incidence of tuberculosis in SLE is higher than general population and is associated with different phenotype and higher mortality. Male gender was associated with increased risk of tuberculosis in SLE.
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Affiliation(s)
- Hafis Muhammed
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India.,Department of General Medicine, Government Medical College, Calicut, India
| | - Avinash Jain
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India.,Division of Clinical Immunology and Rheumatology, SMS Medical College and Hospital, Jaipur, India
| | - Sarit Sekhar Pattanaik
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Rudrarpan Chatterjee
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - R Naveen
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Hina Kabeer
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Latika Gupta
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Durga P Misra
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Vikas Agarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Able Lawrence
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Ramnath Misra
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Amita Aggarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India.
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Oku K, Hamijoyo L, Kasitanon N, Li MT, Navarra S, Morand E, Tanaka Y, Mok CC. Prevention of infective complications in systemic lupus erythematosus: A systematic literature review for the APLAR consensus statements. Int J Rheum Dis 2021; 24:880-895. [PMID: 33999518 DOI: 10.1111/1756-185x.14125] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 04/18/2021] [Indexed: 12/28/2022]
Abstract
Systemic lupus erythematosus (SLE) is a more common autoimmune rheumatic disease in the Asia-Pacific region. The prognosis of SLE remains unsatisfactory in some Asian countries because of delayed diagnosis, limited access to medications, increased complications and issues of tolerability and adherence to treatment. The Asia-Pacific League of Associations for Rheumatology SLE special interest group has recently published a set of consensus recommendations on the management of SLE for specialists, family physicians, specialty nurses, and other healthcare professionals in the Asia-Pacific region. This article reports a systematic literature review of the infective complications of SLE in Asia and evidence for prevention of these infections by pre-emptive antimicrobial therapy and vaccination.
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Affiliation(s)
- Kenji Oku
- Department of Rheumatology, Endocrinology and Nephrology Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Laniyati Hamijoyo
- Rheumatology Division, Department of Internal Medicine, Padjadjaran University, Bandung, Indonesia
| | - Nuntana Kasitanon
- Division of Rheumatology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Meng Tao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
| | - Sandra Navarra
- Section of Rheumatology, University of Santo Tomas Hospital, Manila, Philippines
| | - Eric Morand
- Centre for Inflammatory Diseases, Monash University School of Clinical Sciences, Monash Medical Centre, Melbourne, Vic., Australia
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Chi Chiu Mok
- Division of Rheumatology, Department of Medicine, Tuen Mun Hospital, Hong Kong, Hong Kong
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12
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Battaglia M, Garrett-Sinha LA. Bacterial infections in lupus: Roles in promoting immune activation and in pathogenesis of the disease. J Transl Autoimmun 2020; 4:100078. [PMID: 33490939 PMCID: PMC7804979 DOI: 10.1016/j.jtauto.2020.100078] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/11/2020] [Accepted: 12/16/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Bacterial infections of the lung, skin, bloodstream and other tissues are common in patients with systemic lupus erythematosus (lupus) and are often more severe and invasive than similar infections in control populations. A variety of studies have explored the changes in bacterial abundance in lupus patients, the rates of infection and the influence of particular bacterial species on disease progression, using both human patient samples and mouse models of lupus. OBJECTIVE The aim of this review is to summarize human and mouse studies that describe changes in the bacterial microbiome in lupus, the role of a leaky gut in stimulating inflammation, identification of specific bacterial species associated with lupus, and the potential roles of certain common bacterial infections in promoting lupus progression. METHODS Information was collected using searches of the Pubmed database for articles relevant to bacterial infections in lupus and to microbiome changes associated with lupus. RESULTS The reviewed studies demonstrate significant changes in the bacterial microbiome of lupus patients as compared to control subjects and in lupus-prone mice compared to control mice. Furthermore, there is evidence supporting the existence of a leaky gut in lupus patients and in lupus-prone mice. This leaky gut may allow live bacteria or bacterial components to enter the circulation and cause inflammation. Invasive bacterial infections are more common and often more severe in lupus patients. These include infections caused by Staphylococcus aureus, Salmonella enterica, Escherichia coli, Streptococcus pneumoniae and mycobacteria. These bacterial infections can trigger increased immune activation and inflammation, potentially stimulating activation of autoreactive lymphocytes and leading to worsening of lupus symptoms. CONCLUSIONS Together, the evidence suggests that lupus predisposes to infection, while infection may trigger worsening lupus, leading to a feedback loop that may reinforce autoimmune symptoms.
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Affiliation(s)
- Michael Battaglia
- Department of Biochemistry, State University of New York at Buffalo, Buffalo, NY, 14203, USA
| | - Lee Ann Garrett-Sinha
- Department of Biochemistry, State University of New York at Buffalo, Buffalo, NY, 14203, USA
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13
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Consani Fernández SA, Díaz Cuña CL, Fernández Rey L, Rostán Sellanes S, Maciel Oleggini G, Facal Castro JA. Infections in systemic autoimmune diseases. REUMATOLOGIA CLINICA 2020; 17:S1699-258X(20)30162-5. [PMID: 32843319 DOI: 10.1016/j.reuma.2020.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 06/05/2020] [Accepted: 06/30/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Infections are a major cause of morbidity and mortality in patients with systemic autoimmune diseases. The aim of the present study is to describe the frequency of infections in a historical cohort of the SAD polyclinic of the Maciel Hospital, according to the type of disease and treatment received. MATERIAL AND METHODS An analytical, retrospective and observational study was conducted in 339 patients with SAD attended at the outpatient clinic in the period from January 1, 2012 to February 28, 2019. Infectious complications were analysed according to treatment and disease. RESULTS 339 cases, median age 56, mostly female. Most cases presented SLE (30.1%) and RA (23.6%), followed by antiphospholipid syndrome (20.4%) and Sjögren's syndrome (12.1%). Hydroxychloroquine (66%), followed by corticosteroids (55.5%) were the most frequently used treatments. Thirteen point three percent received biological therapies: 46.9% of the cases presented some infectious complication, 95% were non-opportunistic. Respiratory infections were the most frequent (48.6%) followed by urinary infections (31.7%) and skin and soft tissue infections (17.6%). On comparing the infected and non-infected groups, significant differences were found in the following variables: methotrexate, mycophenolate, corticoids, biological therapies, combination of drugs, active disease, RA and cases with overlap. The use of hydroxychloroquine and sulfasalazine was associated with a lower risk of infection in patients with RA. CONCLUSIONS Infections are a frequent complication in patients with RA, due to the immune disturbances of the disease itself and prescribed treatments, mainly corticoids and biologicals. The importance of screening and infection prophylaxis before starting treatment is stressed.
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Affiliation(s)
| | - Carolina Laura Díaz Cuña
- Asistente de Clínica Médica «3». Hospital Maciel. Udelar. Asistente del Departamento Básico de Medicina. Montevideo. Uruguay
| | - Lucía Fernández Rey
- Asistente de Clínica Médica «3». Hospital Maciel. Udelar. Montevideo. Uruguay
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14
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González-Naranjo LA, Coral-Enríquez JA, Restrepo-Escobar M, Muñoz-Vahos CH, Jaramillo-Arroyave D, Vanegas-García AL, Eraso R, Vásquez G, Jaimes F. Factors associated with active tuberculosis in Colombian patients with systemic lupus erythematosus: a case-control study. Clin Rheumatol 2020; 40:181-191. [PMID: 32529420 DOI: 10.1007/s10067-020-05225-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 05/22/2020] [Accepted: 06/08/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To identify factors associated with active tuberculosis (TB) in patients with systemic lupus erythematosus (SLE). METHODS We performed a retrospective case-control study in two tertiary care teaching hospitals in Medellín, Colombia. From January 2007 to December 2017, a total of 268 patients with SLE were included. SLE patients with TB (cases) were matched 1:3 with SLE patients without TB (controls) by disease duration and the date of the hospitalization in which the diagnosis of TB was made (index date of cases) to the nearest available rheumatology hospitalization in the matched controls (± 2 years). Conditional univariable and multivariable logistic regression analyses were performed. RESULTS Sixty-seven cases and 201 controls were assessed. Only pulmonary TB occurred in 46.3%, only extrapulmonary TB in 16.4% and disseminated TB in 37.3% of cases. Multivariable logistic regression analysis showed that lymphopenia (OR, 2.91; 95% CI 1.41-6.03; P = 0.004), 12-month cumulative glucocorticoid dose ≥ 1830 mg (OR, 2.74; 95% CI 1.26-5.98; P = 0.011), and having been treated with ≥ 2 immunosuppressants during the last 12 months (OR, 2.81; 95% CI 1.16-6.82; P = 0.022) were associated with TB after adjusting for age, sex, ethnicity, disease duration, disease activity, and comorbidity index. A trend towards an association of kidney transplantation with TB was also found (OR, 3.77; 95% CI 0.99-14.30; P = 0.051). CONCLUSION Among SLE patients, cumulative glucocorticoid dose, lymphopenia, and the use of ≥ 2 immunosuppressants during the last 12 months were associated with active TB infection. Key Points • Among SLE patients, a cumulative dose of glucocorticoids equivalent to 5 mg/day of prednisone during the last 12 months is independently associated with the development of TB. • The use of two or more immunosuppressants during the last 12 months is also a risk factor for TB infection development is SLE patients. • Lymphopenia is predominant in SLE patients with TB, being especially profound in those with disseminated TB. • Renal transplant recipients with SLE also have an elevated risk of TB.
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Affiliation(s)
- Luis Alonso González-Naranjo
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Hospital Universitario de San Vicente Fundación, Bloque 7. Calle 64 N°51 D - 154, Medellín, Colombia.
| | - Jaime Alberto Coral-Enríquez
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Hospital Universitario de San Vicente Fundación, Bloque 7. Calle 64 N°51 D - 154, Medellín, Colombia
| | - Mauricio Restrepo-Escobar
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Hospital Universitario de San Vicente Fundación, Bloque 7. Calle 64 N°51 D - 154, Medellín, Colombia
| | - Carlos Horacio Muñoz-Vahos
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Hospital Universitario de San Vicente Fundación, Bloque 7. Calle 64 N°51 D - 154, Medellín, Colombia
| | - Daniel Jaramillo-Arroyave
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Hospital Universitario de San Vicente Fundación, Bloque 7. Calle 64 N°51 D - 154, Medellín, Colombia
| | - Adriana Lucía Vanegas-García
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Hospital Universitario de San Vicente Fundación, Bloque 7. Calle 64 N°51 D - 154, Medellín, Colombia
| | - Ruth Eraso
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Hospital Universitario de San Vicente Fundación, Bloque 7. Calle 64 N°51 D - 154, Medellín, Colombia.,Department of Pediatrics, Division of Rheumatology, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Gloria Vásquez
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Hospital Universitario de San Vicente Fundación, Bloque 7. Calle 64 N°51 D - 154, Medellín, Colombia
| | - Fabián Jaimes
- Department of Internal Medicine, Universidad de Antioquia, Medellín, Colombia.,GRAEPIC - Clinical Epidemiology Academic Research Group (Grupo Académico de Epidemiología Clínica), Universidad de Antioquia, Medellín, Colombia.,Research Direction, Hospital Universitario San Vicente Fundación, Medellín, Colombia
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15
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Park DW, Chung SJ, Yeo Y, Park TS, Lee H, Moon JY, Kim SH, Kim TH, Yoon HJ, Sohn JW. Therapeutic issues with, and long-term outcomes of, pulmonary mycobacterial tuberculosis treatment in patients with autoimmune rheumatic diseases. J Thorac Dis 2020; 11:4573-4582. [PMID: 31903246 DOI: 10.21037/jtd.2019.10.74] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background Real-world data on treatment safety and outcome of pulmonary tuberculosis (PTB) in patients with rheumatic diseases (RDs) are scarce. This study explored the therapeutic issues of standard first-line anti-tuberculosis (TB) medication in patients in whom PTB complicated autoimmune RDs. Methods Observational, retrospective study was conducted in an intermediate TB burden area, South Korea. We evaluated the safety profile of, and adherence to, standard first-line anti-TB medication in PTB patients with systemic RD and assessed the long-term treatment outcomes, up to 84 months after treatment completion. Results We included 37 patients suffering from PTB with RD (case group) and 191 without RD (control group). Rheumatoid arthritis (RA) was the most common RD (24 PTB patients, 64.9%). The frequency of severe adverse drug reactions (ADRs) was significantly higher in the case group than in the control group (36.1% vs. 12.5%, P=0.003). Severe gastrointestinal problems were the most commonly observed ADRs, with a high frequency consistently noted in both groups. Changes in first-line anti-TB medication because of severe ADRs were significantly more frequent in the case group, compared with the control group (19.4% vs. 8.3%, P=0.046). No significant between-group difference was evident in terms of long-term unfavorable outcomes (including relapse and mortality) (5.7% cases vs. 1.2% controls, P=0.146). Conclusions Clinicians may encounter difficulties when treating PTB in patients with RD. Despite the favorable long-term outcomes of RD patients, the outcomes of individual patients such as those with systemic lupus erythematosus (SLE) should be interpreted with caution during post-therapy follow-up.
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Affiliation(s)
- Dong Won Park
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sung Jun Chung
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Yoomi Yeo
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Tai Sun Park
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Hyun Lee
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Ji-Yong Moon
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sang-Heon Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Tae-Hyung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Ho Joo Yoon
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Jang Won Sohn
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
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16
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Elzein F, Elzein A, Mohammed N, Alswailem R. Miliary tuberculosis mimicking systemic lupus erythematosus flare. Respir Med Case Rep 2018; 25:216-219. [PMID: 30237973 PMCID: PMC6143694 DOI: 10.1016/j.rmcr.2018.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 09/07/2018] [Accepted: 09/07/2018] [Indexed: 11/10/2022] Open
Abstract
A 26-year-old woman was diagnosed with and treated for systemic lupus erythematosus (SLE) in 2002. She was admitted 11 years later with nephrotic-range proteinuria and lupus nephritis and received two doses of rituximab after failing on steroids and mycophenolate mofetil. Four months later, she presented with fever and joint pain/swelling. Gram stains, joint aspirates, and blood culture all yielded negative results for bacteria. She was discharged after treatment for a possible flare of lupus, but two weeks later, she presented again with a cough and shortness of breath in addition to the flare symptoms. Synovial fluid Smears, and cultures yielded positive results for Mycobacterium tuberculosis; similarly, sputum polymerase chain reaction test and culture confirmed pulmonary tuberculosis. Tuberculosis is difficult to diagnose in SLE patients; it may present like or precipitate SLE flare. In this patient a presumed SLE flare turned out to be an aggressive miliary, disseminated tuberculosis.
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Affiliation(s)
- Fatehi Elzein
- Infectious Diseases Unit, PSMMC, Riyadh, Saudi Arabia, P.O. Box 7897, Riyadh, 11159, Saudi Arabia
| | - Ahmed Elzein
- Infectious Diseases Unit, PSMMC, Riyadh, Saudi Arabia, P.O. Box 7897, Riyadh, 11159, Saudi Arabia
| | - Nazik Mohammed
- Infectious Diseases Unit, PSMMC, Riyadh, Saudi Arabia, P.O. Box 7897, Riyadh, 11159, Saudi Arabia
| | - Ramiz Alswailem
- Rheumatology Division, PSMMC, Riyadh, Saudi Arabia, P.O. Box 7897, Riyadh, 11159, Saudi Arabia
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17
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18
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Torres-González P, Romero-Díaz J, Cervera-Hernández ME, Ocampo-Torres M, Chaires-Garza LG, Lastiri-González EA, Atisha-Fregoso Y, Bobadilla-Del-Valle M, Ponce-de-León A, Sifuentes-Osornio J. Tuberculosis and systemic lupus erythematosus: a case-control study in Mexico City. Clin Rheumatol 2018; 37:2095-2102. [PMID: 29675624 DOI: 10.1007/s10067-018-4109-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/21/2018] [Accepted: 04/10/2018] [Indexed: 12/19/2022]
Abstract
To determine, among systemic lupus erythematosus patients, factors associated with active tuberculosis. We performed a case-control study, in a tertiary-care center in Mexico City. We defined cases as systemic lupus erythematosus patients with active tuberculosis and matched them 1:1 with systemic lupus erythematosus patients without tuberculosis (controls) by age, date of systemic lupus erythematosus diagnosis, and disease duration. We analyzed clinical variables, lupus disease activity (SLEDAI-2K), and accumulated damage (SLICC/ARC-DI). We performed a nonconditional logistic regression to determine factors associated with tuberculosis. We identified 72 tuberculosis cases among systemic lupus erythematosus patients, 58% were culture confirmed. Thirty-three percent (24/72) were pulmonary only, 47.2% (34/72) extrapulmonary only, and 19.4% both. After adjustment for age, gender, and socioeconomic status, SLEDAI-2K and SLICC/ARC-DI, a 1-year cumulative dose of prednisone ≥ 3 g (odds ratios (OR), 18.85; 95% confidence interval (95% CI), 6.91-51.45) was associated with tuberculosis, and the antimalarial treatment was protective (OR, 0.13; 95% CI, 0.04-0.36). Among systemic lupus erythematosus patients, cumulative dose of prednisone is associated with tuberculosis. Further research is required to elucidate the protective effect of antimalarial drugs for tuberculosis. Preventive strategies must be implemented in patients at risk.
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Affiliation(s)
- Pedro Torres-González
- Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Juanita Romero-Díaz
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Mario Ocampo-Torres
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Luis Gerardo Chaires-Garza
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Av. Vasco de Quiroga 15, Colonia Belisario Domínguez Sección XVI, Delegación Tlalpan, 14080, Mexico City, Mexico
| | - Ernesto Alejandro Lastiri-González
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Av. Vasco de Quiroga 15, Colonia Belisario Domínguez Sección XVI, Delegación Tlalpan, 14080, Mexico City, Mexico
| | - Yemil Atisha-Fregoso
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Av. Vasco de Quiroga 15, Colonia Belisario Domínguez Sección XVI, Delegación Tlalpan, 14080, Mexico City, Mexico
| | - Miriam Bobadilla-Del-Valle
- Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Alfredo Ponce-de-León
- Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - José Sifuentes-Osornio
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Av. Vasco de Quiroga 15, Colonia Belisario Domínguez Sección XVI, Delegación Tlalpan, 14080, Mexico City, Mexico.
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19
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Combined Diagnosis of Systemic Lupus Erythematosus and Tuberculosis in an Irish Adolescent Female. Case Rep Pediatr 2018; 2018:2031219. [PMID: 29666738 PMCID: PMC5865275 DOI: 10.1155/2018/2031219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 01/30/2018] [Indexed: 11/17/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease of unknown aetiology, which can affect any organ system. Tuberculosis (TB) is a common infection in SLE because of immune dysregulation associated with the latter. We report a case of an adolescent female who presented with a year's history of polyarticular arthralgia and fever. Physical examination revealed a large left effusion that needed drainage. Investigations revealed a combined diagnosis of SLE and TB. Management comprised quadruple anti-TB therapy and SLE treatment. She made a steady recovery and has maintained a stable state from the lupus perspective.
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20
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Teh CL, Wan SA, Ling GR. Severe infections in systemic lupus erythematosus: disease pattern and predictors of infection-related mortality. Clin Rheumatol 2018; 37:2081-2086. [DOI: 10.1007/s10067-018-4102-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 03/16/2018] [Accepted: 04/10/2018] [Indexed: 10/17/2022]
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21
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Calle E, González LA, Muñoz CH, Jaramillo D, Vanegas A, Vásquez G. Tuberculous sacroiliitis in a patient with systemic lupus erythematosus: a case report and literature review. Lupus 2018. [DOI: 10.1177/0961203318762594] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Systemic lupus erythematosus (SLE) patients are at higher risk of developing opportunistic infections such as tuberculosis (TB), especially extrapulmonary forms like osteoarticular TB, compared to the general population. However, tuberculous sacroiliitis has been scarcely reported in these patients. We present a 34-year-old woman with SLE who developed articular tuberculosis simultaneously affecting the right sacroiliac joint and the left knee. The patient was successfully treated with antituberculosis therapy for nine months. In this case, in addition to the immunological abnormalities of lupus, the long-term glucocorticoid therapy at high dosages was the main risk factor for the development of osteoarticular tuberculosis.
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Affiliation(s)
- E Calle
- División de Reumatología, Departamento de Medicina Interna, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | - L A González
- División de Reumatología, Departamento de Medicina Interna, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | - C H Muñoz
- División de Reumatología, Departamento de Medicina Interna, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
- Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - D Jaramillo
- División de Reumatología, Departamento de Medicina Interna, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | - A Vanegas
- División de Reumatología, Departamento de Medicina Interna, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
- Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - G Vásquez
- División de Reumatología, Departamento de Medicina Interna, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
- Sección de Inmunogenética, Universidad de Antioquia, Medellín, Colombia
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22
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Hussein DAEM, Habeeb RAEM, El-Azizi NO, Salah El-Deen NNM, Morad CS, Hawwash AM. Mycobacterium tuberculosis infection in systemic lupus erythematosus patients. THE EGYPTIAN RHEUMATOLOGIST 2017. [DOI: 10.1016/j.ejr.2017.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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23
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Cooray S, Zhang H, Breen R, Carr-White G, Howard R, Cuadrado M, D’Cruz D, Sanna G. Cerebral tuberculosis in a patient with systemic lupus erythematosus following cyclophosphamide treatment: a case report. Lupus 2017; 27:670-675. [DOI: 10.1177/0961203317722849] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- S Cooray
- Louise Coote Lupus Unit, Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, UK
- Department of Respiratory Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - H Zhang
- Louise Coote Lupus Unit, Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, UK
| | - R Breen
- Department of Respiratory Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - G Carr-White
- Cardiothoracic Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - R Howard
- Department of Neurology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - M Cuadrado
- Louise Coote Lupus Unit, Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, UK
| | - D D’Cruz
- Louise Coote Lupus Unit, Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, UK
| | - G Sanna
- Louise Coote Lupus Unit, Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, UK
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González-García A, Fortún J, Elorza Navas E, Martín-Dávila P, Tato M, Gómez-Mampaso E, Moreno S. The changing epidemiology of tuberculosis in a Spanish tertiary hospital (1995-2013). Medicine (Baltimore) 2017; 96:e7219. [PMID: 28658113 PMCID: PMC5500035 DOI: 10.1097/md.0000000000007219] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Important epidemiological changes and improvement of new diagnostic approaches, mainly molecular tools, might have impacted the management and outcome of tuberculosis (TB) in the last years in industrialized countries. In order to describe the epidemiological trends, and changes in clinical, diagnostic, and therapeutic aspects in patients with TB, an observational study was performed in a tertiary hospital in Western Europe (Madrid, Spain).All adult patients (>16 years) with a diagnosis of TB in the period 1995 to 2013 were included in the study.TB was diagnosed in 1284 patients, including 304 (24%) foreign-born and 298 (23.2%) human immunodeficiency virus (HIV)-infected patients. The proportion of foreign-born patients increased significantly, from 7.4% (1995) to 40.3% (2013), P < .001, while the proportion of patients with HIV infection decreased (from 41% to 15%, P < .001). Extrapulmonary locations of TB increased (from 23.9% to 37.1%, P < .001), although the miliary forms were less frequent (from 16% to 5.6%, P < .001). Pulmonary involvement remained constant during the period of study (from 50% to 46%, P = .18). The yield of microbiological diagnostic methods in different clinical specimens has remained very similar. Only molecular techniques have improved the diagnosis in respiratory, urinary, and peritoneal samples. The global cure rate was 64.8% and mortality rate was 9.1% (6.5% directly attributable to TB). Mortality has decreased significantly during the years of study (from 11% to 2%, P < .001).There has been a significant decline in the number of patients with TB. Changes in HIV coinfection and immigration have conditioned other epidemiological and clinical aspects of the disease, including the clinical presentation, treatment response, and mortality. Only the use of molecular tests has provided an improvement in the diagnosis of pulmonary and extrapulmonary TB.
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Affiliation(s)
| | | | | | | | - Marta Tato
- Department of Microbiology, University Hospital Ramón y Cajal, University of Alcalá, IRYCIS, Madrid, Spain
| | - Enrique Gómez-Mampaso
- Department of Microbiology, University Hospital Ramón y Cajal, University of Alcalá, IRYCIS, Madrid, Spain
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The risk of tuberculosis in SLE patients from an Asian tertiary hospital. Rheumatol Int 2017; 37:1027-1033. [PMID: 28286903 DOI: 10.1007/s00296-017-3696-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 03/04/2017] [Indexed: 12/11/2022]
Abstract
Systemic lupus erythematosus (SLE) has been associated with increased risk of tuberculosis (TB). However, little is known about the extent and risk factors for TB among Asian patient with SLE. We aimed to assess the rate of TB in patients with SLE, and investigate the risk of SLE on TB development using hospital administrative database. This is an historical cohort study of hospital discharge database from 2004 to 2011 to identify cases with SLE and TB using International Statistical Classification of Diseases and Related Health Problems, 9th Revision, Australian Modification (ICD-9-AM) codes. Of 301568 hospitalized patients, 841 (0.3%) patients had SLE, 1843 (0.6%) patients had TB, including 17 SLE patients (2.0%). SLE patients had a significantly higher rate of TB (2.0 vs. 0.6%, p < 0.001) compared to that of patients without SLE. The differences in the higher rate after breaking down was in the pulmonary TB group (1.7 vs. 0.5%, p < 0.00) but not in extrapulmonary TB group (0.4 vs. 0.1%, p = 0.060). Logistic regression analyses showed that SLE was a significant and independent predictor of TB (odds ratio 4.6, 95% CI 2.8-7.5, p < 0.001) after adjustment for factors such as age group, gender, ethnicity, admission class, nutritional deficiency, organ transplantation, and Charlson comorbidity index. SLE patients were found to experience higher rates of tuberculosis in this group of Asian patient population. Patients with SLE should be considered as a high-risk group for TB, active screening for latent patients and treatment for positive TB patients is needed.
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Bhattacharya PK, Jamil M, Roy A, Talukdar KK. SLE and Tuberculosis: A Case Series and Review of Literature. J Clin Diagn Res 2017; 11:OR01-OR03. [PMID: 28384925 PMCID: PMC5376776 DOI: 10.7860/jcdr/2017/22749.9398] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 10/21/2016] [Indexed: 12/24/2022]
Abstract
Systemic Lupus Erythematosus (SLE) and Tuberculosis (TB) are intricately related with an increase in the risk of TB in SLE. Primary mechanisms pertaining to the increased susceptibility for TB are the inherent immunodeficient state of SLE and use of immunosuppressant agents in the treatment of SLE. We report a case series of five female patients of SLE with TB who presented between January 2015 and December 2015 in a tertiary care teaching hospital in North Eastern India. All the patients were young to middle aged females having SLE with or without lupus nephritis who were on immunosuppressive therapy with corticosteroids, mycophenolate mofetil or cyclophosphamide. Two of the cases had sputum positive pulmonary tuberculosis while rest had Extra-Pulmonary TB (EPTB). The response to anti-tubercular therapy led to clinical improvement in all the cases except one who had an adverse outcome. Our series further substantiates the increased risk of TB in SLE thus, prompting further research towards better management of these two disease entities in conjunction.
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Affiliation(s)
- Prasanta Kumar Bhattacharya
- Professor and Head, Department of General Medicine, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India
| | - Md Jamil
- Assistant Professor, Department of General Medicine, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India
| | - Aakash Roy
- Postgraduate Student, Department of General Medicine, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India
| | - Kishore Kumar Talukdar
- Postgraduate Student, Department of General Medicine, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India
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Rúa-Figueroa Í, López-Longo J, Galindo-Izquierdo M, Calvo-Alén J, Del Campo V, Olivé-Marqués A, Pérez-Vicente S, Fernández-Nebro A, Andrés M, Erausquin C, Tomero E, Horcada L, Uriarte E, Freire M, Montilla C, Sánchez-Atrio A, Santos G, Boteanu A, Díez-Álvarez E, Narváez J, Martínez-Taboada V, Silva-Fernández L, Ruiz-Lucea E, Andreu JL, Hernández-Beriain JÁ, Gantes M, Hernández-Cruz B, Pérez-Venegas J, Pecondón-Español Á, Marras C, Ibáñez-Barceló M, Bonilla G, Torrente V, Castellví I, Alegre JJ, Calvet J, Marenco JL, Raya E, Vázquez T, Quevedo V, Muñoz-Fernández S, Rodríguez-Gómez M, Ibáñez J, Pego-Reigosa JM. Incidence, associated factors and clinical impact of severe infections in a large, multicentric cohort of patients with systemic lupus erythematosus. Semin Arthritis Rheum 2017; 47:38-45. [PMID: 28259425 DOI: 10.1016/j.semarthrit.2017.01.010] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Revised: 01/16/2017] [Accepted: 01/23/2017] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To estimate the incidence of severe infection and investigate the associated factors and clinical impact in a large systemic lupus erythematosus (SLE) retrospective cohort. METHODS All patients in the Spanish Rheumatology Society Lupus Registry (RELESSER) who meet ≥4 ACR-97 SLE criteria were retrospectively investigated for severe infections. Patients with and without infections were compared in terms of SLE severity, damage, comorbidities, and demographic characteristics. A multivariable Cox regression model was built to calculate hazard ratios (HRs) for the first infection. RESULTS A total of 3658 SLE patients were included: 90% female, median age 32.9 years (DQ 9.7), and mean follow-up (months) 120.2 (±87.6). A total of 705 (19.3%) patients suffered ≥1 severe infection. Total severe infections recorded in these patients numbered 1227. The incidence rate was 29.2 (95% CI: 27.6-30.9) infections per 1000 patient years. Time from first infection to second infection was significantly shorter than time from diagnosis to first infection (p < 0.000). Although respiratory infections were the most common (35.5%), bloodstream infections were the most frequent cause of mortality by infection (42.0%). In the Cox regression analysis, the following were all associated with infection: age at diagnosis (HR = 1.016, 95% CI: 1.009-1.023), Latin-American (Amerindian-Mestizo) ethnicity (HR = 2.151, 95% CI: 1.539-3.005), corticosteroids (≥10mg/day) (HR = 1.271, 95% CI: 1.034-1.561), immunosuppressors (HR = 1.348, 95% CI: 1.079-1.684), hospitalization by SLE (HR = 2.567, 95% CI: 1.905-3.459), Katz severity index (HR = 1.160, 95% CI: 1.105-1.217), SLICC/ACR damage index (HR = 1.069, 95% CI: 1.031-1.108), and smoking (HR = 1.332, 95% CI: 1.121-1.583). Duration of antimalarial use (months) proved protective (HR = 0.998, 95% CI: 0.997-0.999). CONCLUSIONS Severe infection constitutes a predictor of poor prognosis in SLE patients, is more common in Latin-Americans and is associated with age, previous infection, and smoking. Antimalarials exerted a protective effect.
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Affiliation(s)
- Íñigo Rúa-Figueroa
- Rheumatology Department, Doctor Negrín University Hospital Las Palmas de Gran Canaria, Bco. de la Ballena s/n, 35020 Las Palmas, Spain.
| | - Javier López-Longo
- Rheumatology Department, Gregorio Marañón University Hospital, Madrid, Spain
| | | | - Jaime Calvo-Alén
- Rheumatology Department, Sierrallana Hospital, Torrelavega, Spain
| | - Víctor Del Campo
- Preventive Medicine Service, Biomedical Research Institute of Vigo (IBIV), University Hospital Complex of Vigo, Vigo, Spain
| | | | - Sabina Pérez-Vicente
- Statistical Department, Research Unit, Spanish Society of Rheumatology (SER), Madrid, Spain
| | | | - Mariano Andrés
- Rheumatology Department, Hospital of Alicante, Alicante, Spain
| | - Celia Erausquin
- Rheumatology Department, Doctor Negrín University Hospital Las Palmas de Gran Canaria, Bco. de la Ballena s/n, 35020 Las Palmas, Spain
| | - Eva Tomero
- Rheumatology Department, La Princesa University Hospital, Madrid, Spain
| | - Loreto Horcada
- Rheumatology Department, Hospital of Navarra, Pamplona, Spain
| | - Esther Uriarte
- Rheumatology Department, Donostia Hospital, Donostia, Guipuzcoa, Spain
| | - Mercedes Freire
- Rheumatology Department, University Hospital Complex of A Coruña, A Coruña, Spain
| | - Carlos Montilla
- Rheumatology Department, Salamanca University Hospital, Salamanca, Spain
| | - Ana Sánchez-Atrio
- System Diseases and Oncology Service, Príncipe de Asturias University Hospital Alcalá de Henares, Madrid, Spain
| | - Gregorio Santos
- Rheumatology Department, Marina Baixa Hospital, Alicante, Spain
| | - Alina Boteanu
- Rheumatology Department, Ramon y Cajal University Hospital, Madrid, Spain
| | | | - Javier Narváez
- Rheumatology Department, Bellvitge Hospital, Barcelona, Spain
| | | | | | | | - José Luis Andreu
- Rheumatology Department, Puerta de Hierro-Majadahonda Hospital, Madrid, Spain
| | | | - Marian Gantes
- Rheumatology Department, University Hospital of Canarias, Tenerife, Spain
| | | | - José Pérez-Venegas
- Rheumatology Department, Jerez de la Frontera University Hospital, Cádiz, Spain
| | | | - Carlos Marras
- Rheumatology Department, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | | | - Gema Bonilla
- Rheumatology Department, La Paz University Hospital, Madrid, Spain
| | - Vicente Torrente
- Rheumatology Department, Hospital of Hospitalet-Moisés Broggi CSI, Barcelona, Spain
| | - Iván Castellví
- Rheumatology Unit, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | | | - Joan Calvet
- Rheumatology Department, Parc Taulí Hospital, Barcelona, Spain
| | - Jose Luis Marenco
- Rheumatology Department, Virgen de Valme University Hospital, Sevilla, Spain
| | - Enrique Raya
- Rheumatology Department, San Cecilio Hospital, Granada, Spain
| | - Tomás Vázquez
- Rheumatology Department, Lucus Augusti Hospital, Lugo, Spain
| | | | | | | | - Jesús Ibáñez
- Rheumatology Unit, POVISA Medical Center, Vigo, Spain
| | - José M Pego-Reigosa
- Rheumatology Department, Biomedical Research Institute of Vigo (IBIV), University Hospital Complex of Vigo, Vigo, Spain
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Multifocal Osteoarticular Tuberculosis in a Lupus With Sjogren Syndrome Patient. Am J Ther 2016; 24:e498-e499. [PMID: 27574932 DOI: 10.1097/mjt.0000000000000478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Erdozain JG, Ruiz-Irastorza G, Egurbide MV, Martinez-Berriotxoa A, Aguirre C. High risk of tuberculosis in systemic lupus erythematosus? Lupus 2016; 15:232-5. [PMID: 16686263 DOI: 10.1191/0961203306lu2289xx] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The incidence and severity of tuberculosis (TB) in patients with systemic lupus erythematosus (SLE) varies greatly among different series. In addition, prospective data are scarce. The aim of this study is to analyse the frequency and severity of TB in our cohort of lupus patients. We analysed data from a prospective database of a single center cohort of 232 patients with SLE (ACR criteria). Prophylaxis with isoniazid was not regularly administered. We identified all cases of TB diagnosed during 10 years (January 1994 to December 2003). The following variables were analysed: annual incidence of TB, location of infection and response to therapy. Data from published series reporting on the incidence of TB among SLE patients were extracted. Three patients (1.3%) suffered clinically manifest TB in 1603 patient-years of follow-up, resulting in an incidence of 187 cases/100 000 patient-years (95% CI 39-547). The pooled annual incidence of TB infection in our area during this period was 30/100 000 individuals. We recorded two cases of pulmonary TB and one case of tuberculous pleurisy. All patients had good response to therapy. The annual incidence of TB among SLE patients in other series, most of them from developing countries, varied between 150/100 000 patients in Turkey and 2450/100 000 patients in India. Of note, high prevalence of extrapulmonary forms as well as elevated TB-associated mortality was reported in most series. TB was more frequent in SLE patients than expected in the general population. We did not see any cases of disseminated infection and all patients had good response to treatment. Our data compare favourably in terms of incidence, severity and outcome with those from highly endemic areas.
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Affiliation(s)
- J G Erdozain
- Department of Internal Medicine, Hospital de Cruces, University of the Basque Country, Bizkaia, Spain
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Guinard E, Bulai Livideanu C, Barthélémy H, Viguier M, Reguiai Z, Richard M, Jullien D, Beneton N, Bara C, Vabres P, Grandvuillemin A, Marguery M, Amelot F, Konstantinou M, Bagheri H, Paul C. Active tuberculosis in psoriasis patients treated with TNF antagonists: a French nationwide retrospective study. J Eur Acad Dermatol Venereol 2016; 30:1336-41. [DOI: 10.1111/jdv.13633] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 01/20/2016] [Indexed: 12/17/2022]
Affiliation(s)
- E. Guinard
- Service de dermatologie; CHU Toulouse Larrey; Université Paul Sabatier; Toulouse France
| | - C. Bulai Livideanu
- Service de dermatologie; CHU Toulouse Larrey; Université Paul Sabatier; Toulouse France
| | | | - M. Viguier
- Service de dermatologie; CHU Saint Louis; Paris France
| | - Z. Reguiai
- Service de dermatologie; CHU de Reims; Reims France
| | - M.A. Richard
- Service de dermatologie; Hôpital Timone; Assistance publique des Hôpitaux de Marseille; Université Aix Marseille; Marseille France
- UMR 911; INSERM CRO2, “Centre de recherche en oncologie biologique et onco phamacologie; Marseille France
| | - D. Jullien
- Service de dermatologie; CHU Lyon; Université de Lyon; Lyon France
| | - N. Beneton
- Service de dermatologie; CH du Mans; Le Mans France
| | - C. Bara
- Service de dermatologie; CH du Mans; Le Mans France
| | - P. Vabres
- Service de dermatologie; CHU Dijon; Dijon France
| | | | - M.C. Marguery
- Service de dermatologie; CHU Toulouse Larrey; Université Paul Sabatier; Toulouse France
| | - F. Amelot
- Service de dermatologie; CHU Toulouse Larrey; Université Paul Sabatier; Toulouse France
| | - M.P. Konstantinou
- Service de dermatologie; CHU Toulouse Larrey; Université Paul Sabatier; Toulouse France
| | - H. Bagheri
- Service de pharmacologie médicale et clinique; CHU Toulouse; Toulouse France
| | - C. Paul
- Service de dermatologie; CHU Toulouse Larrey; Université Paul Sabatier; Toulouse France
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Chen D, Yang Z, Yang Y, Zhan Z, Yang X. A Rare Case of Disseminated Tuberculosis of the Bone Marrow in Systemic Lupus Erythematosus: Case Report. Medicine (Baltimore) 2016; 95:e3552. [PMID: 27149470 PMCID: PMC4863787 DOI: 10.1097/md.0000000000003552] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Patients with systemic lupus erythematosus (SLE) are susceptible to tuberculosis (TB), especially in endemic areas such as China. The variable and nonspecific clinical features of disseminated TB often leads to an erroneous or misdiagnosis. When a patient presents with TB of the bone marrow, the clinical condition is more perplexing and the prognosis is typically poor. Till now, there is no case report after apatinib came in the market.Here, we report a case of TB of the bone marrow accompanied with SLE. The patient exhibited remarkable features, including widespread lesions in the lungs, spinal vertebrae, sacrum, and ilium that were found to be consistent with TB of the bone marrow after histopathological examination.This case highlights the importance of clinical suspicion for TB during the follow-up of SLE patients, especially in endemic areas. An aggressive diagnostic biopsy should be performed in suspected TB patients as early as possible.
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Affiliation(s)
- Dongying Chen
- From the Department of Rheumatology (DC, YY, ZZ, Xiuyan Yang), the First Affiliated Hospital of Sun Yat-sen University, Guangzhou,China; and Department of Pathology (ZY), the First Affiliated Hospital of Sun Yat-sen University, Guangzhou,China
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Freire PS, Montoni JD, Ribeiro AS, Marques HH, Mauad T, Silva CA. Tuberculose miliar: infecção oportunista grave em pacientes com lúpus eritematoso sistêmico juvenil. REVISTA BRASILEIRA DE REUMATOLOGIA 2016. [DOI: 10.1016/j.rbr.2014.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Research Progress on Systemic Lupus Erythematosus Complicated with Infection. INFECTION INTERNATIONAL 2015. [DOI: 10.1515/ii-2017-0106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AbstractIn recent years, in treatment standardization of systemic lupus erythematosus (SLE), infections and serious complications became the leading cause of death related to this disease, exceeding those of renal involvement and lupus encephalopathy. SLE coinfection is mainly related to defects in humoral immunity and cellular immunity, SLE disease activity, and doses of hormone and immune inhibitors.
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Freire PS, Montoni JD, Ribeiro ASM, Marques HH, Mauad T, Silva CA. Miliary tuberculosis: a severe opportunistic infection in juvenile systemic lupus erythematosus patients. REVISTA BRASILEIRA DE REUMATOLOGIA 2014; 56:274-9. [PMID: 27267647 DOI: 10.1016/j.rbre.2014.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 04/14/2014] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION One of the main issues in juvenile systemic lupus erythematosus (JSLE) patients is infection, such as tuberculosis (TB). Of note, SLE patients are susceptible to pulmonary and extrapulmonary TB. However, to our knowledge, this contagious disease was rarely reported in pediatric lupus population, particularly diffuse or miliary TB. Therefore, from January 1983 to December 2011, 5,635 patients were followed-up at our Pediatric Rheumatology Unit and 285 (5%) of them met the American College of Rheumatology classification criteria for SLE. CASE REPORTS Four (1.4%) of our JSLE patients had disseminated TB and were described herein. All of them were female gender, received BCG vaccination and did not have a history of TB household contact. The median of current age at TB diagnosis and the period between JSLE and TB diagnosis were 17 years old (range 14-20) and 5.5 years (range 2-7), respectively. All patients developed miliary TB during the course of the disease. The median of SLE Disease Activity Index 2000 (SLEDAI-2K) was 4 (2-16) and the patients were treated with immunosuppressive agents (glucocorticoid, azathioprine and/or intravenous cyclophosphamide). Two of them presented sepsis and TB diagnosis was only established at autopsy, especially with lungs, central nervous system and abdominal involvements. Anti-TB therapy (isoniazid, rifampicin and pyrazinamide) was indicated in the other two TB cases, however they deceased. DISCUSSION Miliary TB is a rare and severe opportunist infection in pediatric lupus population. This study reinforces the importance of routine searches for TB in JSLE patients.
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Affiliation(s)
- Priscilla S Freire
- Pediatric Rheumatology Unit, Instituto da Criança, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil
| | - João D Montoni
- Pediatric Rheumatology Unit, Instituto da Criança, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Aline S M Ribeiro
- Pediatric Rheumatology Unit, Instituto da Criança, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Heloísa H Marques
- Pediatric Infectious Diseases Unit, Instituto da Criança, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Thais Mauad
- Department of Pathology, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Clovis A Silva
- Pediatric Rheumatology Unit, Instituto da Criança, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil; Division of Rheumatology, Instituto da Criança, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil.
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Kobayashi I, Mori M, Yamaguchi KI, Ito S, Iwata N, Masunaga K, Shimojo N, Ariga T, Okada K, Takei S. Pediatric Rheumatology Association of Japan recommendation for vaccination in pediatric rheumatic diseases. Mod Rheumatol 2014; 25:335-43. [DOI: 10.3109/14397595.2014.969916] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Ruangnapa K, Dissaneewate P, Vachvanichsanong P. Tuberculosis in SLE patients: rare diagnosis, risky treatment. Clin Exp Med 2014; 15:429-32. [PMID: 25099176 DOI: 10.1007/s10238-014-0302-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 07/07/2014] [Indexed: 10/24/2022]
Abstract
We document three cases of tuberculosis (TB) in 237 systemic lupus erythematosus (SLE) patients. Their ages at SLE and TB diagnoses were 13/15, 10/25, and 13/24 years. All were female and in all the TB was diagnosed during a period of lupus flare-up when they were receiving prednisolone and other immunosuppressive drugs. All three patients had extrapulmonary TB: Two had miliary TB and one had disseminated TB through the muscles, left knee joint, and lungs. All three patients experienced anti-TB drug-induced hepatotoxicity manifesting as jaundice along with elevated transaminase enzymes from the first-line anti-TB drugs they received, leading to a change to second-line drugs in two of them. In conclusion, although TB in SLE patients is not common, it should be considered when a patient is nonresponsive to the SLE treatment. Higher rates of extrapulmonary TB and anti-TB drug-induced hepatotoxicity in SLE patients with TB were noted.
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Affiliation(s)
- Kanokpan Ruangnapa
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, 90110, Thailand
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Diagnosis of latent tuberculosis in patients with systemic lupus erythematosus: T.SPOT.TB versus tuberculin skin test. BIOMED RESEARCH INTERNATIONAL 2014; 2014:291031. [PMID: 25009813 PMCID: PMC4058455 DOI: 10.1155/2014/291031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 04/08/2014] [Accepted: 04/09/2014] [Indexed: 11/18/2022]
Abstract
Early studies in patients with systemic lupus erythematosus (SLE) reported increased incidence of tuberculosis. The tuberculin skin test (TST) is the technique of choice to detect latent tuberculosis infection (LTBI) but has several limitations. Objectives. We compared TST and the newer T.SPOT.TB test to diagnose LTBI in SLE patients. Methods. In this observational cohort study conducted between August 2009 and February 2012, we recruited 92 patients from those attending the SLE clinic of our university hospital. Data recorded were epidemiological and sociodemographic characteristics. Laboratory analyses included TST and T.SPOT.TB tests. Results. Of the patients studied, 92% were women with an average age of 42.7 years. Overall, the degree of correlation between the two tests was low (Kappa index = 0.324) but was better in patients not receiving corticosteroids (CTC)/immunosuppressive (IS) therapy (Kappa = 0.436) and in those receiving hydroxychloroquine (Kappa = 0.473). While TST results were adversely affected by those receiving CTC and/or IS drugs (P = 0.021), the T.SPOT.TB results were not. Conclusion. Although the TST test remains a useful tool for diagnosing LTBI in SLE patients, the T.SPOT.TB test is perhaps better employed when the patient is receiving CTC and/or IS drugs.
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Tazi Mezalek Z, Bono W. Challenges for lupus management in emerging countries. Presse Med 2014; 43:e209-20. [PMID: 24857588 DOI: 10.1016/j.lpm.2014.04.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 04/03/2014] [Indexed: 12/23/2022] Open
Abstract
In emerging countries, systemic lupus erythematosus (SLE) has been associated with several unfavorable outcomes including disease activity, damage accrual, work disability and mortality. Poor socioeconomic status (SES) and lack of access to healthcare, especially in medically underserved communities, may be responsible for many of the observed disparities. Diagnostic delay of SLE or for severe organ damages (renal involvement) have a negative impact on those adverse outcomes in lupus patients who either belong to minority groups or live in emerging countries. Longitudinal and observational prospective studies and registries may help to identify the factors that influence poor SLE outcomes in emerging countries. Infection is an important cause of mortality and morbidity in SLE, particularly in low SES patients and tuberculosis appears to be frequent in SLE patients living in endemic areas (mainly emerging countries). Thus, tuberculosis screening should be systematically performed and prophylaxis discussed for patients from these areas. SLE treatment in the developing world is restricted by the availability and cost of some immunosuppressive drugs. Moreover, poor adherence has been associated to bad outcomes in lupus patients with a higher risk of flares, morbidity, hospitalization, and poor renal prognosis. Low education and the lack of money are identified as the main barrier to improve lupus prognosis. Newer therapeutic agents and new protocols had contributed to improve survival in SLE. The use of corticoid-sparing agents (hydroxychloroquine, methotrexate, azathioprine and mycophenolate mofetif) is one of the most useful strategy; availability of inexpensive generics may help to optimize access to these medications.
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Affiliation(s)
- Zoubida Tazi Mezalek
- Université Mohamed V Souissi, Faculté de médecine et de pharmacie, 10000 Rabat, Morocco; Ibn Sina University Hospital, internal medicine department, 10000 Rabat, Morocco.
| | - Wafaa Bono
- Hassan II University Hospital, internal medicine and immunology Clinic, Fès, Morocco
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Webster AS, Shandera WX. The extrapulmonary dissemination of tuberculosis: A meta-analysis. Int J Mycobacteriol 2014; 3:9-16. [PMID: 26786217 DOI: 10.1016/j.ijmyco.2014.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 01/27/2014] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVE The epidemiology of the forty percent of tuberculosis patients who present with disseminated and/or extrapulmonary disease is in need of further study. Further study of such dissemination using published data from international indices may provide data which assist with control of tuberculosis. METHODS For each clinical or epidemiologic factor studied, summary odds ratios and corresponding 95% confidence intervals were calculated showing associations between such factors and documented extrapulmonary dissemination of tuberculosis. RESULTS Eighteen studies fulfilled criteria for study of the clinical factors and nine for the cytokine studies. Significant factors associated with a greater risk of extrapulmonary dissemination were female gender (summary odds ratio, 1.92 (95% confidence intervals, 1.72-2.13), I-squared 86.9), age under 45 (1.37, 1.18-1.60, 63.7), and as well the absence of smoking, drinking and diabetes but not HIV infection (1.10, 0.91-1.32, 80.5). Among cytokines, the macrophage receptor protein P2X7 was associated most strongly associated with extrapulmonary dissemination of tuberculosis (2.28, 0.88-5.90, 92.9). CONCLUSION Young age, female gender, and the macrophage purinergic receptor protein P2X7 were major factors associated with extrapulmonary dissemination of tuberculosis.
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Affiliation(s)
| | - Wayne Xavier Shandera
- Division of General Medicine, Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA.
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Tuberculosis infection in primary Sjögren's syndrome: a nationwide population-based study. Clin Rheumatol 2013; 33:377-83. [PMID: 24170112 DOI: 10.1007/s10067-013-2408-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 09/07/2013] [Accepted: 09/30/2013] [Indexed: 12/23/2022]
Abstract
Primary Sjögren's syndrome (pSS) is a systemic autoimmune disease and may complicate with interstitial lung disease. The risk of Mycobacterium tuberculosis (TB) infection in patients with pSS has not been determined. This nationwide population-based study aimed to explore the incidence and risk factors of TB infection in patients with pSS. We identified 4,822 pSS patients from the Taiwan National Health Insurance database and compared the incidence rates of TB infection in these patients with 48,220 randomly selected age-, sex-, and comorbidity-matched subjects without pSS. The Cox proportional hazard model was used to identify risk factors for TB in patients with pSS. The risk of TB was higher in the pSS cohort than in the control cohort with an incidence rate ratio (IRR) of 1.58 (95% confidence interval [95% CI] 1.13-2.18, p = 0.006). The risk factors for TB in the pSS cohort were age ≥60 years (hazard ratio [HR] 3.22, 95% CI 1.78-5.84; p < 0.001), and corticosteroid usage, which had a dose-dependent effect in the pSS patients compared to the nonusers (daily prednisolone dose or equivalent less than 5 mg/day: HR 2.34; p = 0.020, 95% CI 1.14-4.78; 5 mg/day to less than 10 mg/day: HR 4.79, 95% CI 2.15-10.68; p < 0.001; 10 mg/day or more: HR 12.19, 95% CI 4.42-33.63; p < 0.001). Patients with pSS had a higher risk of pulmonary TB in Taiwan, which was related to age ≥60 years and corticosteroid usage.
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Danza A, Ruiz-Irastorza G. Infection risk in systemic lupus erythematosus patients: susceptibility factors and preventive strategies. Lupus 2013; 22:1286-94. [DOI: 10.1177/0961203313493032] [Citation(s) in RCA: 224] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Infection is one of the leading causes of morbidity and mortality in systemic lupus erythematosus (SLE). Bacterial infections are most frequent, followed by viral and fungal infections. The impaired cellular and humoral immune functions seen in patients with SLE are predisposing conditions, whilst disease activity, prednisone doses over 7.5–10 mg/day, high doses of methylprednisolone or cyclophosphamide are well-recognised risk factors for infection. The first six months after rituximab treatment and the use of more than three courses are also associated with an increased susceptibility for infection. It has not been established whether belimumab, azathioprine and mycophenolate mofetil increase the risk of serious infections. Most vaccines are effective and safe in SLE patients, although vaccination should be avoided during periods of active disease. Live virus vaccines are contraindicated for immunosuppressed patients. Influenza and pneumococcal vaccines are universally recommended. Tuberculosis prophylaxis should be considered in selected cases. Therefore, it is advisable not to exceed doses of 5 mg/day of prednisone in chronic treatment. Methylprednisolone and cyclophosphamide should be used in low-dose regimens. Antimalarials have a well-known protective role against infection, in addition to other beneficial properties, thus, hydroxychloroquine is recommended for all SLE patients where no contraindication exists.
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Affiliation(s)
- A Danza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Hospital De Cruces, University of the Basque Country, Spain
- Clinical Department of Medicine, Facultad de Medicina, Universidad de la República, Uruguay
| | - G Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Hospital De Cruces, University of the Basque Country, Spain
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Sciascia S, Cuadrado MJ, Karim MY. Management of infection in systemic lupus erythematosus. Best Pract Res Clin Rheumatol 2013; 27:377-89. [DOI: 10.1016/j.berh.2013.07.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Singh H, Ray S, Kaur M, Gupta V, Kumar H, Talapatra P, Mathur R, Arya S, Ghangas N. Exacerbation of latent lupus: is the culprit acid-fast bacilli or antitubercular therapy? Clin Rheumatol 2013; 32:1233-6. [PMID: 23572037 DOI: 10.1007/s10067-013-2250-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 03/10/2013] [Accepted: 03/27/2013] [Indexed: 10/27/2022]
Abstract
Typical as well as atypical presentations of systemic lupus erythematosus are being increasingly recognized due to improved diagnostic methods. In a tuberculosis-endemic country like India, it was traditionally believed that the occurrence of tuberculosis in lupus was due to the chronic immunosuppression caused by lupus or because of the use of steroids or isoniazid-induced lupus. Increasingly several patients with no recorded predisposition to lupus with a history of treatment for tuberculosis are coming with evidence of systemic lupus erythematosus rather than a drug-limited story. Whether the development of an autoimmune state is a mere conjecture or the presence of acid-fast bacilli in the body for a prolonged duration causes complex antigenic interactions leading to an antigenic response needs to be looked into. We present a report of three such patients and review the pathogenetic interactions that could possibly explain the role of mycobacterial antigens as a putative antigen in the pathogenesis of lupus.
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Affiliation(s)
- Harpreet Singh
- Department of Medicine, Pt. B. D Sharma PGIMS, Rohtak, Haryana, India.
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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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Ayodele OE, Okpechi IG, Swanepoel CR. Long-term renal outcome and complications in South Africans with proliferative lupus nephritis. Int Urol Nephrol 2013; 45:1289-300. [PMID: 23306862 DOI: 10.1007/s11255-012-0376-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2012] [Accepted: 12/26/2012] [Indexed: 02/03/2023]
Abstract
AIM To report the long-term outcome and complication profile of South African patients with proliferative lupus nephritis (PLN). METHODS A retrospective review of 66 patients with biopsy-proven PLN [58 diffuse proliferative LN (Class IV) and 8 focal proliferative LN (Class III)] under our care from January 1995 to December 2009 was done. RESULTS Thirty-three (50 %) patients reached the composite end point of doubling of serum creatinine, end-stage renal disease (ESRD) or death. The 5-, 10- and 15-year cumulative event-free survival rates were 54, 34 and 27 %, respectively. Variables associated with the composite end point were simultaneous diagnosis of SLE and LN (p = 0.048); elevated serum creatinine at onset (p = 0.009); elevated systolic blood pressure (SBP) (p < 0.001) and elevated diastolic blood pressure (DBP) (p < 0.001) on follow-up; and non-remission following induction therapy (p < 0.001). The 5-, 10- and 15-year renal survival rates in our patients were 63, 52 and 52 %, respectively. Hypertension at onset of LN (p = 0.037), nephrotic-range proteinuria (p = 0.033), eGFR < 60 ml/min/1.73 m(2) (p = 0.013) and lack of remission following induction therapy (p < 0.001) were all associated with development of end-stage renal disease (ESRD). Elevated SBP on follow-up (95 % CI 1.03-1.34, p = 0.017) was the only factor associated with composite end point while failure to achieve remission following induction therapy was the only factor associated with ESRD on multivariate analysis. Thirty-five (53 %) patients developed complications with persistent leukopenia, gastritis, sepsis, tuberculosis (TB) and herpes zoster being the leading complications. Ovarian failure occurred in 4 (11 %) patients. CONCLUSION The 5-, 10 and 15-year event-free survival rates were 54, 34 and 27 % and failure to achieve remission following induction therapy predicted poor renal survival on multivariate analysis.
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Affiliation(s)
- Olugbenga E Ayodele
- Division of Nephrology, Department of Medicine, Ladoke Akintola University of Technology, P.O. Box 710, Ogbomoso, Osogbo, Nigeria,
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Arenas Miras MDM, Hidalgo Tenorio C, Jimenez Alonso J. Tuberculosis in patients with systemic lupus erythematosus: Spain's situation. ACTA ACUST UNITED AC 2012; 9:369-72. [PMID: 23102827 DOI: 10.1016/j.reuma.2012.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Revised: 06/13/2012] [Accepted: 06/21/2012] [Indexed: 11/18/2022]
Abstract
There has recently been an increase in the incidence of patients with systemic lupus erythematosus (SLE) due mainly to earlier diagnosis, and increased survival. Tuberculosis in our country is one of the most prevalent infectious diseases, and one of the underlying causes would be HIV infection and increased immigration from areas with high tuberculosis prevalence; this phenomenon is truly important in patients with autoimmune diseases, as clinical presentation, severity and prognosis of tuberculosis are often different to that of immunocompetent patients. Studies of tuberculosis in patients with SLE are scarce and inconclusive, with many doubts existing about the performance or non-tuberculous prophylaxis in this population and the absence of a protocol due to lack of conclusive studies. New techniques for diagnosis of tuberculosis (IGRAs) may be useful in this population due to higher sensitivity than Mantoux, helping avoid false negatives.
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Lin YC, Liang SJ, Liu YH, Hsu WH, Shih CM, Sung FC, Chen W. Tuberculosis as a risk factor for systemic lupus erythematosus: results of a nationwide study in Taiwan. Rheumatol Int 2011; 32:1669-73. [PMID: 21416237 DOI: 10.1007/s00296-011-1847-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Accepted: 02/18/2011] [Indexed: 10/18/2022]
Abstract
A previous study, with relatively small number of patients, showed that prior Mycobacterium tuberculosis (TB) may precipitate SLE in patients from endemic areas. The purpose of the study was to investigate the relationship between prior TB infection and systemic lupus erythematosus (SLE) from the National Health Insurance Research Database (NHIRD) in Taiwan. Cases of SLE and TB were identified from the NHIRD with corresponding ICD-9 codes 710.0 and 011-018, respectively, from January 2000 to December 2008. A total of 2,721 cases of SLE and 10,823 control subjects were included in data analysis. The average annual incidence rate was 8.1 per 100,000. The annual incidence rates of SLE decreased from 6.38 per 100,000 to 2.55 per 100,000 during 2000-2008. Compared with the control subjects, SLE patients were more likely to be white collar workers (P = 0.0005), reside in highly urbanized areas (P = 0.0140), and have higher incomes (P = 0.0088). TB was much more prevalent in SLE patients than in the control subjects (1.8 vs. 0.9%, P < 0.001). The mean time interval between diagnosis of TB and SLE was 45.58 ± 39.0 months. On multivariate analysis, TB was the greatest potential risk factor for precipitating SLE (OR = 2.11, 95% CI = 1.49-3.00). In addition, patients with co-existing TB and DM had a higher risk of SLE than the control group (OR = 3.91, 95% CI 1.84-8.31). In conclusion, this study suggests that there is an increased risk of precipitating SLE among patients with TB in Taiwan from a nationwide health insurance research dataset. Mycobacterial infections could trigger autoimmune diseases in experimental studies. Furthermore, a study with relatively small number of patients revealed that prior TB may precipitate SLE in patients from endemic areas. There is an increased risk of precipitating SLE among patients with TB in Taiwan from a nationwide health insurance research dataset during a 9-year period.
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Affiliation(s)
- Yu-Chao Lin
- Division of Pulmonary and Critical Care Medicine, China Medical University Hospital, Taichung, Taiwan
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van Assen S, Elkayam O, Agmon-Levin N, Cervera R, Doran MF, Dougados M, Emery P, Geborek P, Ioannidis JPA, Jayne DRW, Kallenberg CGM, Müller-Ladner U, Shoenfeld Y, Stojanovich L, Valesini G, Wulffraat NM, Bijl M. Vaccination in adult patients with auto-immune inflammatory rheumatic diseases: a systematic literature review for the European League Against Rheumatism evidence-based recommendations for vaccination in adult patients with auto-immune inflammatory rheumatic diseases. Autoimmun Rev 2010; 10:341-52. [PMID: 21182987 DOI: 10.1016/j.autrev.2010.12.003] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Accepted: 12/11/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To present the systematic literature review (SLR), which formed the basis for the European League Against Rheumatism (EULAR) evidence-based recommendations for vaccination in adult patients with auto-immune inflammatory rheumatic diseases (AIIRD). METHODS AIIRD, vaccines and immunomodulating drugs, as well as eight key questions were defined by the multidisciplinary expert committee commissioned by EULAR for developing the recommendations. A SLR was performed using MedLine through October 2009 and including data from meta-analyses, systematic reviews, randomized trials, and observational studies, excluding case series with ≤ 5 participants. Articles in English and regarding patients ≥ 16 years of age, were eligible. RESULTS Several vaccine-preventable infections (VPI) occur more often in AIIRD-patients and most vaccines are efficacious in AIIRD-patients, even when treated with immunomodulating agents, except rituximab. There does not appear to be an increase in vaccination-related harms in vaccinated patients with AIIRD in comparison with unvaccinated patients with AIIRD. However, these studies are underpowered and therefore not conclusive. CONCLUSION Based on the current evidence from the literature, recommendations for vaccination in patients with AIIRD were made. However, more research is needed in particular regarding incidence of VPI, harms of vaccination and the influence of (new and established) immunomodulating agents on vaccination efficacy.
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Affiliation(s)
- S van Assen
- Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands.
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González León R, Garrido Rasco R, Chinchilla Palomares E, García Hernández FJ, Castillo Palma MJ, Sánchez Román J. [Tuberculosis in a cohort of patients with systemic lupus erythematosus]. ACTA ACUST UNITED AC 2010; 6:256-61. [PMID: 21794726 DOI: 10.1016/j.reuma.2009.11.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Revised: 11/02/2009] [Accepted: 11/03/2009] [Indexed: 11/16/2022]
Abstract
OBJECTIVES 1) To study tuberculosis (TB) infection in a cohort of patients with systemic lupus erythematosus (SLE) and to compare its frequency and characteristics with that of others series. 2) To look for differential characteristic among SLE patients with and without TB. 3) To investigate if there was any relationship between TB's most severe forms and higher doses of glucocorticoids (GC) or other immunosuppressants. PATIENTS AND METHOD Retrospective review of medical records of 789 SLE patients and description of the clinical characteristics of 13 cases of active TB infection among them. Bibliographical search in MEDLINE-PubMed of the SLE/TB series published, using the terms: infection, tuberculosis, systemic lupus erythematosus. Comparative study of clinical, biological and therapeutic differences between cases (SLE/TB+) and controls (SLE/TB) using χ(2) and Fisher exact test. RESULTS Thirteen patients with active tuberculosis were detected (10 women, average age 36 years/SD 11,2/prevalence 1,6%). Nine (69,2%) of them were primary infections and 4 (30,8%) reactivations. Microbiological diagnosis (smear examination for acid-fast bacilli and/or culture on Lowestein-Jensen medium) was established in 11 patients (84,6%). TB Pulmonary manifestations was present in 9 patients (69,2%) and extra-pulmonary manifestations were found in 8 [(61,5%); 6 of them (46%) were disseminated forms]. Nine (69,2%) patients were on GC therapy at the moment TB was diagnosed. Four of the TB patients died (30,8%). Myositis was more frequent in TB cases (p < 0,05). This data is similar to that reported in the literature. CONCLUSIONS In our series, TB mortality was high (30,8%) in a patients with SLE. Frequency of extrapulmonary forms was double than that described in the Spanish population. Patients with higher GC dose had more severe forms of TB.
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Affiliation(s)
- Rocío González León
- Unidad de Colagenosis e Hipertensión Pulmonar, Servicio de Medicina Interna, Hospital Universitario Virgen del Rocío, Sevilla, España
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