系统性红斑狼疮与感染VIP免费

LUPUSVsINFECTIONZhaojiuliangDepartmentofRheumatologyPUMCH,Beijing•Q1.WhatarethemostfrequentinfectionsinpatientswithSLE?•Q2WhicharetheclinicalfactorsinvolvedinthedevelopmentofinfectionsinSLE?•Q3HowcantheriskofinfectiouscomplicationsinSLEbereduced?Q1.WhatarethemostfrequentinfectionsinpatientswithSLE?•Infectionisresponsibleforapproximately25%ofalldeathsinpatientswithsystemiclupuserythematosus(SLE)•Themainreasonofhospitalization•Appearstobehighestwithinthefirst5yearsofdiseaseonsetInfectioninSLEClinRheumatol,2014.33(1):57-63.CharacteristicsofmajorinfectionsinSLERespiratorytractsUrinarytractsSkinandsofttissuesThetypesofinfectionsthatSLEpatientsdevelopedwerethesameasinthegeneralpopulation•Themostfrequentinfectionsinclude:–Pneumonia,herpeszostervirus,andurinarytractinfectionArthritisCareRes(Hoboken),2015.67(8):1078-85.CharacteristicsofmajorinfectionsinSLERelativerisksofhospitalizationsLupuscomparedwithgeneralpopulationArthritisCareRes(Hoboken),2015.67(8):1078-85.PathogenofinfectioninSLEGram-negativebacilli,gram-positivecocci,fungalandotherbacterialinfectionsaccountedfor39.85%,31.58%,18.80%and9.77%,respectivelyofnosocomialinfections.Clinicalmanifestationsofinfections•Atypical!!!Mycobacteriumtuberculosis•TheprevalenceofTBinfectioninSLE:5-30%•Characteristics–higherincidencerate–morefrequentextra-pulmonaryinvolvement–moreextensivepulmonaryinvolvement–Highrelapserateeveniftreatedwithprophylacticizoniazid–morecommoninSLErenaltransplantpatientsZandman-Goddard,G.,InfectionsandSLE.Autoimmunity,2009.38(7):473-485.Mycobacteriumtuberculosis•TBmaypresentasamimickerofvasculitis•TBmaypresentwithskindiseaseposingadiagnosticchallenge•Ahighindexofsuspicionwillallowprompttreatment.•TB.spot–DatainChinaViralinfections•AcuteviralinfectionsinSLE–CMV(~50%)–parvovirusB19–herpessimplex–EBV–varicellazostervirus–hepatitisA–amongotherlessfrequentlyreportedvirusesHZV•Theannualage-adjustedincidenceofherpeszostervirusinSLEpatientsof12/1000person-years•Mostfrequentlyalate(>5yrs)complicationsofSLE•OftenoccurringduringinactivityormildSLEactivity•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-HuntsyndromeCytomegalovirus（CMV）•CMVinfectionandSLEexacerbationmaybedifficulttodistinguish•DevelopmentofSLEmaybetriggeredbyaCMVinfection.•ExistingSLEmayundergoanexacerbationfollowingaCMVinfection•CMVseropositiveVSovertclinicaldisease–Over90%SLEptsareseropositive–Antigenemia18-44%–Overtclinicaldisease:uncommonPneumocystisPneumoniaPneumocystisPneumonia•AcutoffforPCPprophylaxisinanyparticulardisease:3.5%?6%？•however,thefrequencyofPCPvariesgreatlyfromdiseasetodisease.–GPA>SLE>IIM>RA?()•Riskfactors–LowCD4+counts–Lymphocyte<350+GCsandcytotoxictherapy–GCs:meandailydose,cumulativedose,and/orpulsedosingPneumocystisPneumoniaPneumocystisPneumonia•ClinicalManifestations–Highrateofco-infectionwithotherOI,includingCMV,Aspergillus,andCandidaspecies.–Highmortality:32%(CTD-PCP),butonly~1/4weresolelyattributabletoPCPPneumocystisPneumonia•ProposedPCPprophylaxisinPtswithCTD–2ormoreofthefollowing–GCs>=20mg/dfor>4weeks–Currentuseof>=2DMARDs–Absolutelymphocytecount=<350cell/mm3–UnderlyingILD•TMP-SMZ：85%reductioninPCPinfection–Realworldsurvey,50%SLEptsonCYCusingprophylaxia–15.88/1WptsreportsPCPinfection;higherAEsrates–NotsufficientevidencetosupportuniversaluseofprophylaxiaQ2WhicharetheclinicalfactorsinvolvedinthedevelopmentofinfectionsinSLE?Riskfactorsforinfection•Useofsteroidsever•UseofCYC,MMF,CD20mAb•Organdamageresultingfromseverelupus•Severelupusflaresinvolvingthekidneyorcentralnervoussystem•HighSLEdiseaseactivityindex(SLEDAI)Danza,A.andRuiz-Irastorza,G.,Infectionriskinsystemiclupuserythematosuspatients:susceptibilityfactorsandpreventivestrategies.Lupus,2013.22(12):1286-94.•Prednisoneusetobeassociatedwithinfectionrisk,witheach10mgperdayincreaseofprednisoneincreasingtheriskofseriousinfection11-fold.Ruiz-Irastorza,G.,Predictorsofmajorinfectionsinsystemiclupuserythematosus.ArthritisResTher,2009.11(4):R109.LN:感染高危因素ArthritisRheumatol,2015.67(6):1577-85.SLE感染高危因素ArthritisRheumatol,2015.67(6):1577-85.Q3HowcantheriskofinfectiouscomplicationsinSLEbereduced?ForRheumatist•EULARrecommendations–Carefultitrationofcorticosteroidsandotherimmuno-suppressiveagentsagainstdiseaseactivity–Promptevaluationforinfections–Prophylacticuseofantibioticsforptsathighriskofcertaininfections–ImmunizationsGCsinSLE具体预防措施