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Managing Infections for Lupus Patients - Highlights from Dr. Curran's Presentation On August 9, 2012, the LSI hosted an educational teleconference “Managing and Preventing Infections for Lupus Patients” presented by Dr. James Curran. The event included a presentation by Dr. Curran followed by Q&A from the callers. The article below is based on information obtained from the teleconference. The entire transcript will be available online in the next few weeks. The second leading cause of death in SLE is infection – making managing and preventing infections a top priority for lupus patients. Lupus patients are at greater risk for many reasons; most are on immunosuppressive therapy at one point or another, pathogen exposure at office visits and lupus itself causes a dysfunction of the normal immune response to name a few. Treatments may also contribute to the high infection rate. The new biologic medications (rituximab, orencia and Benlysta) can increase the risk of infection. Corticosteroids, including prednisone, increase the risk of infection. The higher the dose of corticosteroids you’re on, the longer you’re on the dose, the greater the risk of infection. The incidence of infections in lupus patients – especially life-threatening infections – appears to be highest in the first five years of the disease. One reason for this might be that in the first five years, patients are undergoing treatment that is modifying their immune response. Infections lupus patients should be mindful of include bacterial, viral and fungal. Some common threats to lupus are pneumococcal pneumonia or streptococcus pneumonia, Haemophilus influenza and staphylococcus aureus. Lupus patients have a predilection towards salmonella which in lupus patients frequently causes osteomyelitis or bone infections. Shingles is more common in lupus patients than the general public. Yeast infections are also common in lupus patients. Other non-hospitalized infections include respiratory tract infection, sinusitis, urinary tract infections and skin infections. Usually with aggressive treatment and early diagnosis, these infections do not require hospitalization. What can you do to protect yourself again getting an infection? First, non-live vaccines are recommended. That would include the flu shot (NOT the flu vaccine administered through the nasal passages), Pneumococcal vaccine every 5-10 years, a Bordetella pertussis booster, Hepatitis B (for healthcare workers) and meningococcal to name a few. If you are on a biologic, be aware that the biologic medicine may impair the normal response to a vaccine. If you have lupus, you should be vaccinated before you use any biologic and before taking major immunosuppressant medications. Plaquenil, hydroxychloroquine, decreases the risk of infections. A 2009 study showed that individuals on Plaquenil are 16 times less likely to get a major infection when taking the drug – regardless of whether or not corticosteroids are also taken. So, patients on corticosteroids and Plaquenil had fewer infections than patients on steroids alone. Other things you can do to manage infections are to be sure to get treated with antibiotics if you are sick. Be sure to use bactericidal drugs – drugs that kill the bacteria instead of freeze it. Lupus patient’s immune system needs to kill the bacteria. In conclusion, remember vaccinations are very important – avoid live viruses. Plaquenil reduces risk of infection. Limit your exposure to infection.

Cryptococcal Meningitis Infections in Lupus often Misdiagnosed News | October 12, 2016 | Lupus By Gregory M. Weiss, M.D. Linked Articles Biologic Tested to Prevent Lupus Flares Lupus Low Disease Activity State Predicts SLE Outcomes Anifrolumab Shows Promise for Lupus At Lupus Diagnosis, Men Generally Worse off than Women Severity More Important than SLE Label in Lupus Overactive Immune System in Lupus Linked to Specific Triggers Gaps in Care Exist for Some Young Lupus Patients Cardiac Events May Occur Before Lupus Starts Walking Test Can be a Measure of Lung Disease in Lupus Biologics in Lupus Might have Different Roles at Different Times Treat-to-Target in Lupus, Not an Impossibility, just Exhaustive Dear Lupus: It’s Time for a Blockbuster Medication Belimumab: Groundbreaker in Lupus Anemia Linked to Restless Legs Syndrome in Lupus Belimumab with Standard Care Works in Lupus Patients The Lupus Action Plan, Explained It’s Time for a Risk Prediction Model for Lupus Preventing and Treating Bone Loss in Lupus Bone Density Scrutiny Critical for Patients with Lupus Cryptococcal Meningitis Infections in Lupus often Misdiagnosed Researchers writing in the journal Emerging Microbes & Infections find that 38 percent of patients with lupus-related cryptococcal meningitis are misdiagnosed. The study, which appears in the Sept. 7 online issue of the journal, is based on a systematic review of data from two hospitals in China and nine literature databases. The final analysis included 38 articles involving 55 cases of cryptococcal meningitis in SLE patients. The researchers found that the prevalence of cryptococcal meningitis in systemic lupus erythematosus patients was 0.5% primarily affecting adult women. A prednisone equivalent of more than 30 mg/day before infection was associated with higher mortality (odds ratio (OR)=9.69 (1.54, 60.73)). In all, 36.8–38.9% patients showed low lupus activity when they developed the crytococcal infection. Microbial infections are one the most important causes of morbidity and mortality in systemic lupus erythematosus patients leading to death in 20–40% of cases, the Chinese researchers wrote. The Risk of Life-Threatening Infections The increased risk of developing life-threatening infections like cryptococcal meningitis is multifactorial. SLE patients using high dose steroids, frequent antibiotics or suffering from high SLE activity are at greater risk for infections in general, the researchers wrote. Inherent disorders of cell-mediated immunity and the high percentage of SLE patients that develop central nervous system (CNS) damage due to autoimmune attack render the blood brain barrier susceptible to invasion from the cryptococcal microbe. Cryptococcal meningitis is deadly and is caused by the fungus cryptococcus neoformans/cryptococcus gattii complex. Cryptococcus is an opportunistic infection that takes advantage of the immune compromised patient. Cryptococcal meningitis is the number one cause of invasive fungal death in patients with systemic lupus erythematosus. The researchers stressed that it is of vital importance that rheumatologists familiarize themselves with CM presentation, severity and treatment while not underestimating its prevalence. Cryptococcal meningitis is ranked as the most important central nervous system infection for SLE patients. It appears that lack of understanding about presentation, prevalence, diagnosis and prevention may be contributing factors that signal a need for a broader dissemination of information about cryptococcal meningitis and lupus. While cryptococcal meningitis in the general population typically strikes males, SLE patients are more often females in their 30s, the review found. It was also discovered that cryptococcal meningitis appeared rather early in the course of SLE progression. This underscores the need for rheumatologists to be on the look out for this infection in young, newly diagnosed patients. The authors review uncovered an important relationship between higher mortality and high dose steroid therapy. Higher doses of corticosteroids are known to increase the risk of infection and now possibly mortality in patients with SLE and cryptococcal meningitis infections. Misdiagnosis also hampers efforts to reduce the incidence of cryptococcal meningitis in SLE patients. More than one third of patients were misdiagnosed largely as a result of failing to sample and test cerebrospinal fluid for fungal pathogens. Defining the Scope of the Problem The first step towards diagnosing, treating and preventing CM in SLE patients is defining the scope of the problem. This is a prevalent and deadly infection that is misdiagnosed in a high percentage of cases. Paying close attention to patient complaints and judicious use of corticosteroids coupled with prophylaxis for high risk patients may help reduce mortality related to CM. Utilizing low cost high yield diagnostic tools like india ink microscopy with a high index of suspicion may increase early diagnosis, especially in developing countries. Ultimately these advances must be accompanied by better access to affordable anti-fungals and clinicians on the front lines armed with the facts. “More emphasis should be placed to further understand lupus-related cryptococcal meningitis and to develop better prophylaxis and management strategies to combat this condition,” researchers wrote. Takeaways Cryptococcal meningitis is the leading cause of invasive fungal infections in patients with SLE. Cryptococcal meningitis is misdiagnosed over one third of the time as a bacterial infection leading to improper treatment. Nearly one-fourth of in systemic lupus erythematosus patients who contracted cryptococcal meningitis died. Symptoms of cryptococcal meningitis in reviewed patients in order from most to least common: Headache, fever, nausea, vomiting and neck rigidity. High dose corticosteroid therapy increases the likelihood of death among those with cryptococcal meningitis and systemic lupus erythematosus. References Fang W, Chen M, Liu J, et al. "Cryptococcal meningitis in systemic lupus erythematosus patients: pooled analysis and systematic review," Emerging Microbes & Infections. Sept. 7, 2016. DOI:10.1038/emi.2016.93 http://www.rheumatologynetwork.com/news/cryptococcal-meningitis-infections-lupus-often-misdiagnosed?GUID=&XGUID=&rememberme=1&ts=13102016