Elsevier

Critical Care Clinics

Volume 18, Issue 4, October 2002, Pages 931-956
Critical Care Clinics

Infections in the immunocompromised rheumatologic patient

https://doi.org/10.1016/S0749-0704(02)00022-2Get rights and content

Section snippets

Predisposing factors to infection

The major predisposing factors to infection in patients with SLE or RA are known to overlap Table 1, Table 2. In SLE patients, alterations in phagocytic cells are common with disease activity [86]. Cellular immunity is impaired, as reflected by lymphopenia, decreased CD4 cell counts, and reduced cytokine production [87], [88]. Reduced immunoglobulin and complement levels have also been reported in SLE patients [89]. Functional asplenia may reduce the elimination of bacteria from the blood

Immunologic effects of corticosteroid use

Certain infectious diseases are associated with chronic steroid use [58]. Predisposition to these infections is attributed to the deleterious effects of steroids on the immune system [92], [93]. Corticosteroid use will result in skin atrophy, easy bruising, and delayed wound healing. These conditions can result in increased access of skin flora to subcutaneous tissue and subsequent infection. Corticosteroid use also leads to neutrophilia, decreased migration of neutrophils to sites of

Other immunosuppressive therapies

Cytotoxic drugs affect the production of phagocytes and lymphocytes. Drugs such as cyclophosphamide, azathioprine, or methotrexate are often given in conjunction with corticosteroids in rheumatic diseases [100], [101]. When cytotoxic drugs are given alone or with alternate-day steroids, there is a significant lowering of infectious complications.

Cyclophosphamide causes neutropenia resulting from decreased production and increased destruction of neurtophils [102]. Hoffman et al reported on 158

New therapies for rheumatoid arthritis (infliximab and etanercept)

Two new biologic agents used in the treatment of rheumatoid arthritis target tumor necrosis factor-α (TNF-α). A chimeric IgG1 monoclonal antibody with high affinity for human TNF-α, infliximab has been shown to improve joint pain and swelling in RA patients [124], [125], [126], [127], [128], [129]. Recent reports, however, have shown an increase in cases of tuberculosis, listeria, and histoplasmosis (Table 4) [130], [131], [132]. Etanercept is a recombinant human TNF receptor protein that binds

Clinical presentations in systemic lupus erythematosus

Fever in SLE patients is commonly observed with disease activity [135], [136]. Eighty percent of patients will have fever documented at least once during this illness. In one series, only 23% of febrile episodes were caused by infections [137]. Clinically it was difficult to distinguish infection from active SLE. Shaking chills occurred in significantly more patients with proven infections (68% versus 27%). Neutrophilic leukocytosis was detected more frequently in febrile patients with

Mortality from infections in systemic lupus erythematosus

One of the most common causes of death in SLE patients is infection [46], [167], [168]. Three recent cohort studies have documented the importance of infections as a cause of death in these patients, and many other studies over 3 decades from many different countries have reported infectious death rates of 0 to 67%, with a mean of 24% [4], [30], [148]. Six studies following patients from the onset of diagnosis (cohort studies) have reported infectious death rates from 6% to 67%, with a mean

Infections in rheumatoid arthritis

Early studies with RA patients suggested that infections account for approximately 25% of all deaths [29], [59], [85], [105]. As with SLE, it has been difficult to separate the effects of immunosuppressive drugs used in treatment from the disease itself. Low-dose methotrexate treatment in RA patients seems to increase infection rates [5], [108]. Postoperative infections in RA patients have also been related to methotrexate use [121]. Stuck et al found no increased risk of infection among

Vaccination for systemic lupus erythematosus and rheumatoid arthritis patients

Because of the morbidity associated with pneumococcal and influenza virus infection, it has been recommended that SLE and RA patients receive approved inactivated vaccines [310], [311]. The two major issues in vaccine administration of these patients are (1) the expected immune response following vaccination, and (2) the potential for worsening the underlying disease. Recent studies have failed to find a relationship between the administration of the pneumococcal vaccine and the influenza virus

Summary

Immunocompromised patients with rheumatic diseases have an increased risk of infections. A major risk factor for infection seems to be the immunosuppressive therapy used. Newer therapies for RA may lead to increased rates of infection by opportunistic pathogens such as Mycobacteria tuberculosis. Because disease manifestation may mimic signs and symptoms of infection, prompt diagnosis may be difficult. Familiarity with the likely infections and their causes should aid in obtaining the

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