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Abstract Number: 772

Cytomegaloviral or Pneumocystis Jiroveci Pneumonia Increases Mortality Rate in Systemic Lupus Erythematosus Patients with Pulmonary Hemorrhage: Evidence from Bronchoalveolar Lavage Fluid Analysis

Chien-Chih Lai, Yi-Syuan Sun and De-Feng Huang, Allergy, Immunology, Rheumatology, Taipei Veterans General Hospital, Taiwan, Taipei City, Taiwan

Meeting: 2018 ACR/ARHP Annual Meeting

Keywords: Infection, morbidity and mortality, pulmonary complications and systemic lupus erythematosus (SLE)

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Session Information

Date: Sunday, October 21, 2018

Session Title: Systemic Lupus Erythematosus – Clinical Poster I: Clinical Manifestations and Comorbidity

Session Type: ACR Poster Session A

Session Time: 9:00AM-11:00AM

Background/Purpose: To evaluate the role of cytomegaloviral or Pneumocystic jiroveci pneumonia (CMV/PJP) in SLE patients with pulmonary hemorrhage (PH).

Methods: We retrospectively examined hospital records for 27 SLE patients with PH who received bronchoalveolar lavage fluid (BALF) analyses. Clinical profile and mortality rates were compared between groups with and without CMV/PJP. Risk factors for PH-related mortality were analyzed.

Results: Among 27 SLE patients with PH, 15 patients had pathogens from BALF samples, and eight patients had CMV/PJP (Table 1). Although CMV/PJP was treated, the 90- and 180-day mortality rates of SLE patients with CMV/PJP were higher than those without these infections (90-day: 62.5% vs. 10.5%, p = 0.011; 180-day: 75% vs. 10.5%, p= 0.002). Risk factors for 90- and 180-day mortality were presence of CMV/PJP (OR 14.2, 95% CI 1.83-109.9; OR 25.5, 95% CI 2.91-223.3) and use of pulse methylprednisolone for PH treatment (OR 12.0, 95% CI 1.48-97.2; OR 8.5, 95% CI 1.13-63.9). Factors increasing the 90-day mortality rate were duration of mechanical ventilation exceeding 14 days (OR 11.1; 95% CI 1.11-112.0) and use of aggressive immunosuppression close to PH onset (OR 7.56; 95% CI 1.09-52.4) (Table 2). Three of the seven patients receiving aggressive immunosuppression died with the presence of CMV/PJP.

Conclusion: Due to the high prevalence of CMV/PJP and its association with mortality, routine BALF analysis is recommended in all suitable SLE patients with PH. Use of aggressive immunosuppression does not benefit SLE patients with opportunistic infections during PH attack.

Table 1. Baseline characteristic of PH of SLE patients.

Parameter

CMV – PJP – (n = 19)

CMV or PJP + (n = 8)

Age at hospitalization, years

33.2 (28.3 ¡V 43.7)

34.2 (32.7 ¡V 56.0)

Female sex

18 (94.7)

8 (100)

Duration of SLE > 3 years

14 (73.7)

5 (62.5)

History of lupus nephritis

17 (89.5)

7 (87.5)

SLEDAI-2K score

12 (7 ¡V 19)

11.5 (3.3 ¡V 20.3)

BAL procedure after PH onset, days

5 (3 ¡V 6)

5.5 (0.75 ¡V 20)

Hemosiderin-laden macrophage in BALF

8 (50)

5 (71.4)

Laboratory data

WBC count, 103/£gL

8.29 (4.8 ¡V 11.3)

6.45 (1.58 ¡V 15.42)

Lymphocyte count, 103/£gL

0.58 (0.35 ¡V 1.00)

0.29 (0.19 ¡V 0.69)

Hemoglobin, g/dL

7.2 (6.0 ¡V 8.0)

7.1 (6.6 ¡V 7.9)

Platelet count, 109/L

87 (57 ¡V 171)

134 (92 ¡V 190)

Serum IgG, mg/dL

934 (699 ¡V 1530)

874 (565 ¡V 874)

Serum creatinine, mg/dL

2.27 (1.21 ¡V 4.25)

2.51 (1.83 ¡V 4.67)

C3, mg/dL

47.6 (34.0 ¡V 67.0)

59.4 (46.3 ¡V 79.4)

C4, mg/dL

12.4 (5.1 ¡V 17.8)

15.1(9.4 ¡V 28.7)

Anti-dsDNA antibody positivity

9 (47.4)

3 (37.5)

Background medications

Prednisolone equivalent, mg/day

10 (5 ¡V 15)

17.5 (11.3 ¡V 23.8)

Hydroxychloroquine

4 (21.1)

2 (25)

Azathioprine

4 (21.1)

2 (25)

Mycophenolate

3 (15.8)

2 (25)

Calcineurin inhibitors

2 (10.5)

1 (12.5)

Cyclophosphamide*

3 (15.8)

0

Rituximab**

1 (5.3)

1 (12.5)

Ventilator usage

15 (78.9)

7 (87.5)

APACH II score†

26 (22 ¡V 27)

24 (24 ¡V 28)

SOFA score†

9 (8 ¡V 11)

8 (6 ¡V 12)

ECMO usage†

0

2 (33.3)

Treatment for PH

Plasmapheresis

11 (57.9)

4 (50)

IVIg

2 (10.5)

4 (50)‡

IV pulse methylprednisolone

2 (10.5)

4 (50)‡

Cyclophosphamide

0

1 (12.5)

Values are presented as median (interquartile range) or number (percentage).

*Within 3 months or **6 months before PH.

†Only for patients ever supported with MV.

‡p < 0.05 vs. patients without CMV pneumonia or PJP.

Table 2. Risk factor analysis for 90-day and 180-day mortality rates in SLE patients with PH

Variable

90-day mortality

180-day mortality

OR

95% Cl

p

OR

95% Cl

p

SLEDAI-2K > 10

0.89

0.16-5.08

0.895

0.58

0.11-3.10

0.527

PDN >7.5 mg/day

2.14

0.20-22.5

0.525

2.69

0.26-27.8

0.406

Serum IgG <751 mg/dL

0.92

0.12-6.83

0.932

0.92

0.12-6.83

0.932

Bacteremia

5.83

0.87-38.9

0.069

3.61

0.64-20.3

0.145

Pathogens in BALF

Bacteria

0.74

0.11-4.87

0.757

1.30

0.23-7.32

0.766

CMV/PJP

14.2

1.83-109.9

 0.011*

25.5

2.91-223.3

 0.003*

MV >14 days

11.1

1.11-112.0

0.041

5.14

0.81-32.8

0.083

Treatment of PH

Plasmapheresis

7.33

0.74-72.6

0.089

3.33

0.53-20.9

0.199

Pulse MP

12.0

1.48-97.2

0.020

8.50

1.13-63.9

0.038

IVIg

1.60

0.22-11.5

0.640

1.25

0.18-8.73

0.822

Aggressive IS close to PH

7.56

1.09-52.4

0.041

5.33

0.83-34.1

0.077

*The only factor that remained significant when selecting variables with p < 0.05 in multivariable analysis. (90-day, OR: 14.2, 95% Cl: 1.83, 109.9; p = 0.011; 180-day, OR: 25.5, 95% Cl: 2.91, 223.3, p = 0.003)

ANCA, antineutrophil cytoplasmic antibody; APACHE II, Acute Physiology and Chronic Health Evaluation II; BAL, bronchoalveolar lavage; ECMO, extracorporeal membrane oxygenation; IgG, immunoglobulin G; IVIg, intravenous immunoglobulin; IS, immunosuppression; MV, Mechanical ventilation; MP, methylprednisolone; PDN, prednisolone; PH, pulmonary hemorrhage; SLEDAI-2K, Systemic Lupus Erythematosus Disease Activity Index 2000; SOFA, sequential organ failure assessment; WBC, white blood cell.


Disclosure: C. C. Lai, None; Y. S. Sun, None; D. F. Huang, None.

To cite this abstract in AMA style:

Lai CC, Sun YS, Huang DF. Cytomegaloviral or Pneumocystis Jiroveci Pneumonia Increases Mortality Rate in Systemic Lupus Erythematosus Patients with Pulmonary Hemorrhage: Evidence from Bronchoalveolar Lavage Fluid Analysis [abstract]. Arthritis Rheumatol. 2018; 70 (suppl 10). https://acrabstracts.org/abstract/cytomegaloviral-or-pneumocystis-jiroveci-pneumonia-increases-mortality-rate-in-systemic-lupus-erythematosus-patients-with-pulmonary-hemorrhage-evidence-from-bronchoalveolar-lavage-fluid-analysis/. Accessed March 8, 2021.
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