系统性红斑狼疮与感染.pptx

LUPUS Vs INFECTION Zhao jiuliang Department of Rheumatology PUMCH,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 SLE?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 systemic lupus erythematosus(SLE)The main reason of hospitalization Appears 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 in SLE Respiratory tracts Urinary tracts Skin 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 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 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 nosocomial infections.Clinical manifestations of infections Atypical!Mycobacterium tuberculosis The prevalence of TB infection in SLE:5-30%Characteristics higher incidence rate more frequent extra-pulmonary involvement more extensive pulmonary involvement High relapse rate even if treated with prophylactic izoniazid more common in SLE renal transplant patients Zandman-Goddard,G.,Infections and SLE.Autoimmunity,2009.38(7):473-485.Mycobacterium tuberculosis TB may present as a mimicker of vasculitis TB may present with skin disease posing a diagnostic challenge A high index of suspicion will allow prompt treatment.TB.spot Data in China Viral infections Acute viral infections in SLE CMV(50%)parvovirus B19 herpes simplex EBV varicella zoster virus hepatitis A among other less frequently reported viruses HZV The annual age-adjusted incidence of herpes zoster virus in SLE patients of 12/1000 person-years Most frequently a late(5yrs)complications of SLE Often occurring during inactivity or mild SLE activity 往往皮疹重而神经系统表现轻 溃疡性角膜炎 耳带状疱疹，Ramsay-Hunt syndrome Cytomegalovirus（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 infection CMV seropositive VS overt clinical disease Over 90%SLE pts are seropositive Antigenemia 18-44%Overt clinical disease:uncommon Pneumocystis Pneumonia Pneumocystis Pneumonia A cut off for PCP prophylaxis in any particular disease:3.5%?6%？however,the frequency of PCP varies greatly from disease to disease.GPASLEIIMRA?()Risk factors Low CD4+counts Lymphocyte=20mg/d for 4weeks Current use of=2 DMARDs Absolute lymphocyte count=350 cell/mm3 Underlying ILD TMP-SMZ：85%reduction in PCP infection Real world survey,50%SLE pts on CYC using prophylaxia 15.88/1W pts reports PCP infection;higher AEs rates Not sufficient evidence to support universal use of prophylaxia 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 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 preventive 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.,Predictors 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 the 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 infections Prophylactic use of antibiotics for pts at high risk of certain infections Immunizations GCs in SLE 具体预防措施