Cytomegaloviral or Pneumocystis Jiroveci Pneumonia Increases Mortality in Systemic Lupus Erythematosus Patients with Pulmonary Hemorrhage: Evidence from Bronchoalveolar Lavage Fluid

Persistent inflammation-immunosuppression-catabolism syndrome in patients with systemic lupus erythematosus

OBJECTIVE

To evaluate the clinical characteristics and prognosis of systemic lupus erythematosus (SLE) with persistent inflammation-immunosuppression-catabolism syndrome (PICS).

METHODS

We retrospectively analyzed patients with SLE who were admitted to the renal intensive care unit (ICU) for over 14 days at Jinling Hospital from July 2010 to July 2018. According to the diagnostic criteria of PICS, we divided the SLE patients into a PICS group and a non-PICS group. We performed a multivariate Cox regression analysis on the risk factors for death in these two groups by comparing the clinical features and prognosis.

RESULTS

A total of 96 SLE patients met the inclusion and exclusion criteria of this study, including 61 patients in the PICS group and 35 patients in the non-PICS group. The PICS group patients required a longer length of stay in ICU with higher inflammatory indicators (such as C-reactive protein, procalcitonin and interleukin-6) and lower immune levels (such as total, CD3 + , CD4 + , CD8 + and CD20 + lymphocytes) compared to the non-PICS group patients (P < 0.01). Hemoglobin, platelets, serum creatinine, serum blood urea nitrogen and SLE Disease Activity Index (SLE-DAI) score in the PICS group were lower than those in the non-PICS group (P < 0.05), suggesting severe hematological injury in the PICS group and relatively severe renal damage in the non-PICS group. The rates of PICS combined with sepsis, acute respiratory distress syndrome, mechanical ventilation, gram-positive bacteria, gram-negative bacteria, fungi and double infections were higher than those in the non-PICS group (P < 0.05). The 3-year survival rate was 50.82% in the PICS group and 85.71% in the non-PICS group. The 3-year renal survival rate was 32.79% in the PICS group and 51.43% in the non-PICS group. Multivariate Cox regression found that the total lymphocyte count during ICU admission was an independent risk factor for death in SLE patients with PICS.

CONCLUSION

Patients with SLE complicated with PICS had longer ICU stays, a lower level of SLE activity, a higher risk of secondary infection and a significantly lower survival rate than non-PICS patients.

Acute respiratory viral adverse events during use of antirheumatic disease therapies: A scoping review

INTRODUCTION

COVID-19 is an acute respiratory viral infection that threatens people worldwide, including people with rheumatic disease, although it remains unclear to what extent various antirheumatic disease therapies increase susceptibility to complications of viral respiratory infections.

OBJECTIVE

The present study undertakes a scoping review of available evidence regarding the frequency and severity of acute respiratory viral adverse events related to antirheumatic disease therapies.

METHODS

Online databases were used to identify, since database inception, studies reporting primary data on acute respiratory viral infections in patients utilizing antirheumatic disease therapies. Independent reviewer pairs charted data from eligible studies using a standardized data abstraction tool.

RESULTS

A total of 180 studies were eligible for qualitative analysis. While acknowledging that the extant literature has a lack of specificity in reporting of acute viral infections or complications thereof, the data suggest that use of glucocorticoids, JAK inhibitors (especially high-dose), TNF inhibitors, and anti-IL-17 agents may be associated with an increased frequency of respiratory viral events. Available data suggest no increased frequency or risk of respiratory viral events with NSAIDs, hydroxychloroquine, sulfasalazine, methotrexate, azathioprine, mycophenolate mofetil, cyclophosphamide, or apremilast. One large cohort study demonstrated an association with leflunomide use and increased risk of acute viral respiratory events compared to non-use.

CONCLUSION

This scoping review identified that some medication classes may confer increased risk of acute respiratory viral infections. However, definitive data are lacking and future studies should address this knowledge gap.

Bronchoalveolar lavage fluid analysis and mortality risk in systemic lupus erythematosus patients with pneumonia and respiratory failure

BACKGROUND

Our aim was to characterize etiologic diagnoses obtained from bronchoalveolar lavage fluid (BALF) and blood specimens, and to identify risk factors for mortality in systemic lupus erythematosus (SLE) patients with pneumonia and respiratory failure.

METHODS

We conducted a retrospective analysis of SLE patients with pneumonia and respiratory failure. Clinical characteristics, laboratory profiles, and microbiology in BALF and blood samples were evaluated. We performed univariable analyses to identify mortality risk factors.

RESULTS

All 24 patients (F:M = 21:3, median age 46.5 years; disease duration 11 years) received mechanical ventilation (median duration: 11 days). Pathogens identified in BALF included Pneumocystis jiroveci (12 patients [50%]), cytomegalovirus (CMV, 7 patients [29.2%]), and bacteria (11 patients [45.8%]). Thirteen patients (54.2%) yielded pathogens in blood (CMV in 8 patients [33.3%] and Escherichia coli in 5 patients [20.8%]). Eight developed septic shock, and 9 died within 30 days. Univariable analysis identified thrombocytopenia (odds ratio [OR]: 8.0, 95% confidence interval [CI]: 1.23-52.25), bacteremia within 30 days before or after endotracheal intubation (OR: 8.0, 95% CI: 1.23-52.5), and P. jiroveci pneumonia (PJP, OR: 7.0, 95% CI: 1.04-46.95) as risk factors for 30-day mortality. Kaplan-Meier analysis confirmed an increased risk of 30-day mortality with thrombocytopenia and bacteremia.

CONCLUSION

There are high prevalence rates of PJP and CMV infections as evidenced by BALF analyses in SLE patients with pneumonia and respiratory failure. BALF analysis can facilitate rescue therapy per pathogen. Thrombocytopenia, bacteremia, and PJP in SLE patients can increase their 30-day mortality, so warrant early and aggressive treatments.