Low prevalence of Pneumocystis pneumonia in hospitalized patients with systemic lupus erythematosus: review of a clinical data warehouse

Abstract

Objective In the era of powerful immunosuppression, opportunistic infections are an increasing concern in systemic lupus erythematosus. One of the best-studied opportunistic infections is Pneumocystis pneumonia; however, the prevalence of Pneumocystis pneumonia in systemic lupus erythematosus is not clearly defined. This study evaluates the prevalence of Pneumocystis pneumonia in hospitalized systemic lupus erythematosus patients, with a focus on validating the Pneumocystis pneumonia and systemic lupus erythematosus diagnoses with clinical information. Methods This retrospective cohort study evaluates the prevalence of Pneumocystis pneumonia in all systemic lupus erythematosus patients treated at Columbia University Medical Center-New York Presbyterian Hospital between January 2000 and September 2014, using electronic medical record data. Patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and patients with renal transplants (including both early and late post-transplant patients) represented immunocompromised control groups. Patients with systemic lupus erythematosus, Pneumocystis pneumonia, HIV/AIDS, or renal transplant were identified using diagnostic codes from the International Classification of Diseases, Ninth Revision (ICD-9). Results Out of 2013 hospitalized systemic lupus erythematosus patients, nine had presumed Pneumocystis pneumonia, yielding a low prevalence of Pneumocystis pneumonia in systemic lupus erythematosus of 0.45%. Three of the nine Pneumocystis pneumonia cases were patients with concomitant systemic lupus erythematosus and HIV/AIDS. Only one of these nine cases was histologically confirmed as Pneumocystis pneumonia, in a patient with concomitant systemic lupus erythematosus and HIV/AIDS and a CD4 count of 13 cells/mm. The prevalence of Pneumocystis pneumonia in renal transplant patients and HIV/AIDS patients was 0.61% and 5.98%, respectively. Conclusion Given the reported high rate of adverse effects to trimethoprim-sulfamethoxazole in systemic lupus erythematosus and the low prevalence of Pneumocystis pneumonia in hospitalized systemic lupus erythematosus patients, our data do not substantiate the need for Pneumocystis pneumonia prophylaxis in systemic lupus erythematosus patients, except in those with concurrent HIV/AIDS.

Hydroxychloroquine may reduce risk of Pneumocystis pneumonia in lupus patients: a Nationwide, population-based case-control study

“…However, we think that regular quality control surveys of NHIRD among all medical facilities by the BNHI has much improved the accuracy of coding in NHIRD [27], and bias attributed by the misclassification was hence minimised. Additionally, the prevalence of PCP infection in the present Taiwanese research was quite similar to those in other studies [19,20].…”

Prevalence of progressive multifocal leukoencephalopathy (PML) in adults and children with systemic lupus erythematosus

“…However, our method allowed a higher sensitivity for identifying all patients with SLE. 10 The true prevalence of PML in SLE, RA, HIV and renal transplants therefore can only be estimated using this method to identify patients. In addition, given the retrospective nature of our study, patients with PML who were not clinically identified with the JC virus infection may not have been included.…”

“…Patients with SLE were identified using ICD-9 code 710.0 or 695.4, an alternative SLE diagnosis code, which has been verified with chart review. 10 The use of an SLE ICD code from even a single hospitalisation allowed a higher sensitivity for identifying all patients with SLE and PML, with a 66% positive predictive value (PPV) for SLE in our cohort. 10 A thorough chart review allowed for confirmation of SLE with PML diagnoses.…”

“…10 The use of an SLE ICD code from even a single hospitalisation allowed a higher sensitivity for identifying all patients with SLE and PML, with a 66% positive predictive value (PPV) for SLE in our cohort. 10 A thorough chart review allowed for confirmation of SLE with PML diagnoses. Patients with HIV/AIDS were identified using ICD-9 code V08 or 042.…”

Pneumocystis pneumonia in a patient with lupus nephritis

“…The resultant immunosuppression increases the risk of opportunistic infections. However unlike most opportunistic infections, pneumocystis pneumonia (PCP) has a low prevalence of 0.45% in immunocompromised SLE patients (7). Lower lymphocyte count right before the onset of PCP and the higher dose of steroid therapy along with depressed CD4+ counts are considered possible risk factors for the development of PCP infection in SLE patients (8).…”