系統(tǒng)性紅斑狼瘡與感染

1、LUPUS Vs INFECTION,Zhao jiuliangDepartment of RheumatologyPUMCH, Beijing,Q1. What are the most frequent infections in patients with SLE? Q2 Which are the clinical factors involved in the development of infections in S

2、LE? Q3 How can the risk of infectious complications in SLE be reduced?,Q1. What are the most frequent infections in patients with SLE?,,,Infection is responsible for approximately 25% of all deaths in patients with syst

3、emic lupus erythematosus (SLE) The main reason of hospitalizationAppears to be highest within the first 5 years of disease onset,Infection in SLE,Clin Rheumatol, 2014. 33(1): 57-63.,Characteristics of major infections

4、in SLE,Respiratory tractsUrinary tractsSkin and soft tissues,The types of infections that SLE patients developed were the same as in the general population,The most frequent infections include:Pneumonia, herpes zoster

5、 virus, and urinary tract infection,Arthritis Care Res (Hoboken), 2015. 67(8): 1078-85.,Characteristics of major infections in SLE,Relative risks of hospitalizations,Lupus compared with general population,Arthritis Care

6、Res (Hoboken), 2015. 67(8): 1078-85.,Pathogen of infection in SLE,Gram-negative bacilli, gram-positive cocci, fungal and other bacterial infections accounted for 39.85%, 31.58%, 18.80% and 9.77%, respectively of nosocomi

7、al infections.,Clinical manifestations of infections,Atypical !!!,Mycobacterium tuberculosis,The prevalence of TB infection in SLE: 5-30%Characteristicshigher incidence rate more frequent extra-pulmonary involvement

8、more extensive pulmonary involvement High relapse rate even if treated with prophylactic izoniazidmore common in SLE renal transplant patients,Zandman-Goddard, G., Infections and SLE. Autoimmunity, 2009. 38(7): 473-485

9、.,Mycobacterium tuberculosis,TB may present as a mimicker of vasculitisTB may present with skin disease posing a diagnostic challenge A high index of suspicion will allow prompt treatment.TB.spotData in China,Viral

10、infections,Acute viral infections in SLECMV(~50%)parvovirus B19herpes simplexEBVvaricella zoster virushepatitis Aamong other less frequently reported viruses,HZV,The annual age-adjusted incidence of herpes zoster

11、virus in SLE patients of 12/1000 person-yearsMost frequently a late(>5yrs) complications of SLEOften occurring during inactivity or mild SLE activity往往皮疹重而神經(jīng)系統(tǒng)表現(xiàn)輕潰瘍性角膜炎耳帶狀皰疹， Ramsay-Hunt syndrome,Cytomegalovirus

12、（CMV）,CMV infection and SLE exacerbation may be difficult to distinguish Development of SLE may be triggered by a CMV infection.Existing SLE may undergo an exacerbation following a CMV infectionCMV seropositive VS ov

13、ert clinical diseaseOver 90% SLE pts are seropositiveAntigenemia 18-44%Overt clinical disease: uncommon,Pneumocystis Pneumonia,Pneumocystis Pneumonia,A cut off for PCP prophylaxis in any particular disease: 3.5%? 6%？

14、however, the frequency of PCP varies greatly from disease to disease. GPA>SLE>IIM>RA?()Risk factorsLow CD4+ countsLymphocyte<350+GCs and cytotoxic therapyGCs: mean daily dose, cumulative dose, and/or pul

15、se dosing,Pneumocystis Pneumonia,Pneumocystis Pneumonia,Clinical ManifestationsHigh rate of co-infection with other OI, including CMV, Aspergillus, and Candida species.High mortality: 32%(CTD-PCP), but only ~1/4 were s

16、olely attributable to PCP,Pneumocystis Pneumonia,Proposed PCP prophylaxis in Pts with CTD2 or more of the followingGCs>=20mg/d for >4weeksCurrent use of >=2 DMARDsAbsolute lymphocyte count=<350 cell/mm3U

17、nderlying ILDTMP-SMZ：85% reduction in PCP infectionReal world survey, 50% SLE pts on CYC using prophylaxia15.88/1W pts reports PCP infection; higher AEs ratesNot sufficient evidence to support universal use of prophy

18、laxia,Q2 Which are the clinical factors involved in the development of infections in SLE?,Risk factors for infection,Use of steroids ever Use of CYC, MMF, CD20 mAb Organ damage resulting from severe lupus Severe lupus

19、 flares involving the kidney or central nervous system High SLE disease activity index (SLEDAI),Danza, A. and Ruiz-Irastorza, G., Infection risk in systemic lupus erythematosus patients: susceptibility factors and preve

20、ntive strategies. Lupus, 2013. 22(12): 1286-94.,,Prednisone use to be associated with infection risk, with each 10 mg per day increase of prednisone increasing the risk of serious infection 11-fold.,Ruiz-Irastorza, G.,Pr

21、edictors of major infections in systemic lupus erythematosus. Arthritis Res Ther, 2009. 11(4): R109.,LN:感染高危因素,Arthritis Rheumatol, 2015. 67(6): 1577-85.,SLE感染高危因素,Arthritis Rheumatol, 2015. 67(6): 1577-85.,Q3 How can th

22、e risk of infectious complications in SLE be reduced?,For Rheumatist,EULAR recommendations Careful titration of corticosteroids and other immuno- suppressive agents against disease activity Prompt evaluation for infect