Lupus

Thursday, March 1, 2012

SLE and the dangers of infection


It can be very scary when having lupus and being on certain medications with the higher risk of infection.  Medications like prednisone, methotrexate, imuran, humira, and many more, lower the immune system, therefore causing higher infection rates.  Due to our own immune systems attacking us with SLE, just having the disease makes us more susceptible to infections that can be troublesome.  I had this explained to me by a nurse and fellow autoimmune disease sufferer and I think it is one of the best ways to describe how our immune systems function.  When someone gets sick with a cold or infection that is healthy, their body sends out soldiers to fight the illness, their bodies know where the infection is and how many soldiers to send. When one has lupus our bodies do one of two things, it will either send so many soldiers to fight, more than needed, and our illness like a cold will go away very fast; or our bodies will send out our soldiers to the wrong place like healthy normal cells, and our cold will in turn cause a more serious illness like pneumonia.  Keep in mind, that this doesn't always happen and not everyone with lupus will get a serious illness like pneumonia.  Our bodies are confused, and when we go on medications that suppress the immune system it helps us by controlling the disease from attacking our bodies, but it also makes us more susceptible infection, especially with confused bodies. 


Infections and Immunizations

 http://www.lupus.org/webmodules/webarticlesnet/templates/new_research.aspx?articleid=93&zoneid=3

Why Do People With Lupus Get Infections So Easily?
An individual with lupus is more susceptible to infection than most people for two reasons:
  1. Lupus directly affects a person's immune system and reduces his or her ability to prevent and fight infection.
  2. Many of the drugs used to treat lupus suppress the function of the immune system and leave the body more prone to infection.
Effects Of Medications Used In The Treatment Of Lupus
Cortisone-like drugs (prednisone) and cytotoxic drugs such as azathioprine (Imuran) and cyclophosphamide (Cytoxan) increase a person's susceptibility to infections because they suppress both normal and abnormal immune system function.
However, controlling lupus is usually more important than the danger posed by a possible infection due to the use of immunosuppressive medications.
The risk of infection parallels the dose and the duration of treatment with steroids:
  • a daily dose of 20 mg. of prednisone is enough to impose a significant risk of infection
  • taking steroids every other day ("alternate day" treatment) decreases the risk and incidence of infections
Direct Effects of Lupus On The Immune System
People with lupus have abnormalities in their immune systems, so they are more likely to develop infections. They are more susceptible to infection even if they do not take corticosteroids. Lupus experts such as Dr. Marian Ropes sparingly used steroids in treating her patients in the 1940s and 1950s. Yet, the data she published showed that the majority of her patients developed serious infections, even on low-dose steroids.
Types Of Infection In SLE
Infections in people with lupus fall into two categories.
  1. The first category includes infections with organisms that can affect persons with lupus and the general population:
    • streptococcus (which causes strep throat)
    • staphylococcus (which causes staph infections).
  2. The second category consists of "opportunistic" infections, which are caused by organisms that bring about disease only when the immune system is weakened. Most opportunistic infections are one of three kinds:
    • fungal
    • parasitic
    • protozoan.  
    •  
    •  Fortunately, only a few individuals will need aggressive hospital treatment for infections. The most common infections in people with lupus usually do not require hospitalization. These common infections usually involve:
    • the respiratory tract
    • the urinary tract.
    However, infections in people with lupus tend to last longer and require a longer course of treatment with antibiotics than infections in people who do not have lupus.
    In addition, people with lupus are at an unusually high risk for contracting:
  3. salmonella (a bacteria)
  4. herpes zoster (a virus)
  5. candida (yeast)
Fevers In Lupus
Anyone with lupus who experiences a fever should be thoroughly evaluated, especially if they are also taking aspirin, non-steroidal medications (e.g., Advil, Naprosyn), or steroids, which lower body temperature. Fevers in lupus may be due to:
  • an infection
  • a drug reaction
  • active lupus.
Clinical Evaluation Of Possible Infection
Active lupus and infection may share many symptoms. Furthermore, infection can bring on a lupus flare, or can be difficult to distinguish from a lupus flare. For example, fever and decreased energy are nonspecific symptoms that may be associated with either a lupus flares or an infection.
More specific symptoms, like sore throat or pain on taking a deep breath, may also occur with either a flare of lupus or with infection. Therefore, it is important for a person with lupus to contact his or her physician whenever symptoms are suggestive of either a disease flare or an infection.
Laboratory Tests Used
  • White blood cell counts
    • this test can help a physician distinguish an infection from a lupus flare
    • a low white blood cell count usually suggests active lupus (although certain viruses can also give a low white count)
    • a high white blood cell count suggests infection
  • Culture of throat, urine, blood or stool
  • Complete blood count (CBC)
  • Chest X-ray
  • Some physicians find a C-reactive protein (CRP) blood test to be helpful in deciding whether a person has active lupus or an infection, but this is still controversial.
    Persons with suspected life-threatening infections of unknown source may need to be hospitalized so they can be observed and necessary cultures can be taken. Tests which are performed to help make a rapid diagnosis may include:
  • gallium scanning
  • bone marrow biopsy
  • lymph node biopsy
  • bronchoscopy
Treatment and Prevention of Infection
The treatment of infections in a person with lupus is basically the same as for anyone else; even people taking high doses of immunosuppressive medications for their lupus may respond well to antibiotics.
However, the use of sulfa antibiotics to treat infections in people with lupus should be avoided whenever possible. Thirty percent of people with lupus are allergic to sulfa antibiotics. In addition, these types of antibiotics can:
  • increase photosensitivity
  • increase skin rashes
  • lower white blood cell counts.
Avoiding The Risks of Infection
Infection poses a risk to all people with lupus. However, those treated with immunosuppressives or steroids are at higher risk. To prevent possible infections, people at high risk for infection often benefit from taking antibiotics before dental treatment or surgical procedures. In general, individuals with lupus should avoid exposure to people with colds or other infections. 

Preventing Infection With Immunizations
The risk of certain types of infection can be decreased with immunization (vaccinations). Nearly all individuals with lupus are vaccinated against a variety of diseases with little difficulty.
However, it is theoretically possible that immunization with vaccines that use live viruses will result in a lupus flare. Nevertheless, polio, measles, and tetanus vaccines, which all use live viruses, have been given to hundreds of thousands of people who have lupus, with no adverse reactions. Passive immunization (i.e., vaccinating with a killed virus), poses no problems. Gammaglobulin is an example of a vaccine which uses a nonspecific antibody instead of a live virus.
It should be noted that people with lupus may have adverse reactions to two types of immunizations.
1) First, some who receive allergy shots (immunotherapy) will experience a lupus flare following treatment.
  • In 1989, the World Health Organization recommended that people with autoimmune diseases should not receive certain types of allergy shots.
  • Allergy shots might cause the person to make more anti-DNA and other lupus-related antibodies in addition to making antibodies against the agent causing the allergy.
  • People with lupus are advised to consult their rheumatologist before receiving any type of allergy immunotherapy.
2) Some lupus patients may also experience difficulties after receiving influenza, or "flu" vaccines.
  • Flu vaccines may not work as well if the individual has lupus.
  • Nevertheless, most rheumatologists do recommend vaccinations against the flu.
Patients with lupus are more susceptible to infections because they have altered immune systems, and also because many patients are on treatment (steroids & cytotoxics) that suppresses immune system function, leaving them more prone to infection.
Lupus patients who get infections frequently show worse clinical signs, & require longer treatment than non-lupus patients.
The most common bacterial infections seen in lupus affect the respiratory tract and the urinary tract. Septic arthritis, tuberculosis, salmonella, cold viruses, & shingles are also more common. The most common fungal infection seen in lupus is candida (thrush).
It is important to distinguish between a lupus flare and an infection. Fever and decreased energy are symptoms that are associated with both infections and lupus flares. Any lupus patient who exhibits symptoms that could be an infection or flare should contact her physician. Blood tests such as a white cell count can help to distinguish a flare from an infection.
Patients at high risk of infection should probably take antibiotics before surgical or dental procedures.
Lupus patients should try to minimise their exposure to people who have colds, 'flu, and other infections, although this is easier said than done!
Lupus patients should probably avoid the antibiotics penicillin and septrin (sulfa), as they may exacerbate lupus, and many lupus patients are allergic to them.
It has been previously thought that lupus patients should avoid immunisations because they could exacerbate lupus. However, the vaccine for influenza has now been shown to be safe and effective; the pneumococcal vaccine is also safe, but resultant antibody levels are somewhat lower in patients with SLE. It is not advisable for patients receiving steroids or cytotoxic therapy to have live vaccines, because these drugs cause immune suppression that may promote infection.
Some patients who receive allergy shots (immunotherapy) will have a flare following this treatment. In 1989, the World Health Organisation recommended that patients with autoimmune diseases should not receive allergy shots. Lupus patients should always consult their rheumatologist before receiving immunotherapy.
 
 

From Current Opinion in Rheumatology

Infections in the Lupus Patient: Perspectives on Prevention

Claire Barber; Wayne L. Gold; Paul R. Fortin
Posted: 07/14/2011; Curr Opin Rheumatol. 2011;23(4):358-365. © 2011 Lippincott Williams & Wilkins
 
 

Abstract and Introduction

Abstract

Purpose of review Infections are one of the most common causes of morbidity, hospitalization and death in patients with systemic lupus erythematosus (SLE). The aim of the review is to describe an approach to screening and prevention of infections in patients with SLE based on recent evidence.
Recent findings
This review summarizes what is known about the incidence and risk factors for infection in SLE as well as the limitations of the current literature. An approach to screening for infections such as tuberculosis and viral hepatitis is described as well as use of prophylactic agents and vaccinations.
Summary
We recommend screening for infectious comorbidities such as tuberculosis and viral hepatitis at the first clinical encounter in patients with lupus in addition to recommending pneumococcal vaccination and yearly influenza vaccination. There is currently limited evidence to support antibiotic prophylaxis for SLE patients on immunosuppressive agents to prevent penumocystis or to support screening for cytomegalovirus and further study is required. Lastly, timely antibiotic treatment in patients with lupus who are hospitalized with infectious complications is important, as delayed antibiotic treatment may be associated with increased mortality.

Introduction

Infections are a major cause of mortality in systemic lupus erythematosus (SLE). In a large multicentre European cohort [1] of 1000 patients followed over 10 years, infections represented the cause of death in 25% of cases and active SLE in 26.5%. Other authors have reported similar findings.[2–4] There appears to be a bimodal distribution to death in SLE with infections and active disease causing death early, within the first 5 years of diagnosis, and myocardial infarctions and thrombotic events occurring later.[1,5] Infections are also responsible for 14–50% of hospitalizations in patients with SLE[6–8] and are a cause of significant morbidity. Table 1 summarizes the observations from six recent studies[3,9•,10–12,13•] reporting on infections in lupus and their outcomes.
Literature on infection in SLE is complex and hampered by comparison of different populations including hospitalized and ambulatory cohorts and regional differences in pathogens may also limit generalizability. Opportunistic infections in SLE appear to be rare but may be underreported.[14] Guidelines for antimicrobial prophylaxis exist for persons with HIV[15] or patients undergoing hematopoietic stem-cell transplant[16] and have decreased incidence of death and hospitalization due to opportunistic infections such as pneumocystis.[17] Although prophylaxis against certain infectious pathogens is recommended in certain 'high risk' patients with SLE,[18] no guidelines exist as to what agents should be used and in which patients. In the absence of definitive studies on the use of infection prophylaxis in SLE, we propose a systematic strategy for preventing opportunistic infections in SLE patients starting with their first clinical evaluation and propose that a checklist could be utilized to identify patients at risk of preventable infections to identify opportunities for prevention. The checklist is as follows:
  1. Yearly influenza shot – give or recommend to family medical doctor.
  2. Pneumococcal vaccination – give or recommend to family medical doctor (every 5 years).
  3. Regular pap smears to screen for cervical dysplasia caused by HPV – recommend to family medical doctor or gynaecologist. Gardasil vaccination as per recommendations for the general population. There are currently no recommendations or data regarding the use of the HPV vaccine in patients with SLE outside of recommendations for the general population.
  4. TB skin test prior to starting immunosuppressive agents and treatment with isoniazid (INH) for patients with latent TB infection.
  5. Hepatitis B serology at baseline in all patients.
  6. Hepatitis C serology at baseline in patients with risk factors.
  7. HIV serology at baseline in patients with risk factors.
  8. Screening for strongyloides in patients from endemic areas (strongyloides serology) prior to starting immunosuppressive agents and treatment with ivermectin if infected.





Lupus and infections


Patients with lupus are more susceptible to infections because they have altered immune systems, and also because many patients are on treatment (steroids & cytotoxics) that suppresses immune system function, leaving them more prone to infection.
Lupus patients who get infections frequently show worse clinical signs, & require longer treatment than non-lupus patients.
The most common bacterial infections seen in lupus affect the respiratory tract and the urinary tract. Septic arthritis, tuberculosis, salmonella, cold viruses, & shingles are also more common. The most common fungal infection seen in lupus is candida (thrush).
It is important to distinguish between a lupus flare and an infection. Fever and decreased energy are symptoms that are associated with both infections and lupus flares. Any lupus patient who exhibits symptoms that could be an infection or flare should contact her physician. Blood tests such as a white cell count can help to distinguish a flare from an infection.
Patients at high risk of infection should probably take antibiotics before surgical or dental procedures.
Lupus patients should try to minimise their exposure to people who have colds, 'flu, and other infections, although this is easier said than done!
Lupus patients should probably avoid the antibiotics penicillin and septrin (sulfa), as they may exacerbate lupus, and many lupus patients are allergic to them.
It has been previously thought that lupus patients should avoid immunisations because they could exacerbate lupus. However, the vaccine for influenza has now been shown to be safe and effective; the pneumococcal vaccine is also safe, but resultant antibody levels are somewhat lower in patients with SLE. It is not advisable for patients receiving steroids or cytotoxic therapy to have live vaccines, because these drugs cause immune suppression that may promote infection.
Some patients who receive allergy shots (immunotherapy) will have a flare following this treatment. In 1989, the World Health Organisation recommended that patients with autoimmune diseases should not receive allergy shots. Lupus patients should always consult their rheumatologist before receiving immunotherapy.






 

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