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

Abstract

Objective.To evaluate the role of cytomegaloviral or Pneumocystis jiroveci pneumonia (CMV/PJP) in systemic lupus erythematosus (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 had pathogens from BALF samples, and 8 had CMV/PJP. Although CMV/PJP was treated, the RR for 90- and 180-day mortality rates of SLE patients with CMV/PJP were higher than those without these infections (5.94, 95% CI 1.44–24.48; 7.13, 95% CI 1.81–28.06, respectively). 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, respectively) 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, respectively). 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). Three of the 7 patients receiving aggressive immunosuppression died with the presence of CMV/PJP.Conclusion.Owing to the high prevalence of CMV/PJP and its association with mortality, routine BALF analysis is recommended for all suitable SLE patients with PH. Use of aggressive immunosuppression does not benefit SLE patients with opportunistic infections during PH attack.

Metagenomic next‐generation sequencing for pneumocystis jirovecii pneumonia in patients with connective tissue disease

“…Our study found that CMV co‐infection was more common in patients with PJP than in the non‐PJP patients, which is consistent with previous studies 30 . Some researchers have suggested that CMV impairs the host immune response to P. jirovecii , resulting in delayed clearance and worse clinical outcomes 31–35 . Currently, limited methods are available for the detection of CMV and other viruses.…”

“…30 Some researchers have suggested that CMV impairs the host immune response to P. jirovecii, resulting in delayed clearance and worse clinical outcomes. [31][32][33][34][35] Currently, limited methods are available for the detection of CMV and other viruses. However, mNGS can detect almost all viruses, and should be considered for use in CTD patients to improve PJP and CMV detection rates.…”

Persistent inflammation–immunosuppression–catabolism syndrome in patients with systemic lupus erythematosus

“…Glucocorticoids inhibit the activation, proliferation, differentiation and survival of macrophages, T lymphocytes and other inflammatory cells, and they promote T cell apoptosis [ 18 ]. Long-term application of the above therapies reduces the clearance capacity of fungi and bacteria, and it increases the risk of infection [ 5 , 19 ]. SLE activity leads to a vicious cycle in which immunosuppressants are difficult to reduce or SLE recurs and immunosuppressants have to be increased again.…”