Rheumatology Advance Access originally published online on October 13, 2006
Rheumatology 2007 46(3):539-544; doi:10.1093/rheumatology/kel343
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Invasive fungal infection in systemic lupus erythematosus: an analysis of 15 cases and a literature review
Division of Rheumatology, Allergy and Immunology and 1Division of Infectious Diseases, Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Tao-Yuan, Taiwan.
Correspondence to: Lieh-bang Liou, Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kwei-san Hsiang, Tao-Yuan County, Taiwan 333. E-mail: b890121{at}adm.cgmh.org.tw
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Abstract |
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Objective. To analyse 15 cases of invasive fungal infection and mortality parameters in the largest series in the last 35 yrs of patients with systemic lupus erythematosus (SLE) at a single medical centre.
Methods. Fifteen patients with SLE and invasive fungal infections were retrospectively enrolled. Clinical and laboratory data, fungal species and infected sites, corticosteroid and immunosuppressant doses and SLE disease activity index were assessed retrospectively. Comparison and correlation analyses utilized Fisher's exact test, the chi-square test, Mann–Whitney U-test or the Wilcoxon signed-rank test where appropriate.
Results. In contrast to other review reports, Cryptococcus neoformans was the most commonly identified fungus in this Taiwanese series. Notably, the prevalence of autoimmune haemolytic anaemia and positive results for the anti-cardiolipin antibody in this study were significantly higher than those in SLE patients in general (P < 0.0001 and P < 0.0001, respectively). Fungal infection contributed to cause of death in 7 of 15 (46.7%) patients, of which Cryptococcus neoformans accounted for six of these infections. Low-dose prednisolone (<1 or <0.5 mg/kg/day based on arbitrary division) prior to fungal infection tended to correlate with 1 yr mortality after diagnosis of SLE (P = 0.077 or P = 0.080). However, following fungal infection, patients who died from infection itself had been prescribed with higher prednisolone dose or equivalent than surviving patients (P = 0.016). All SLE patients with fungal infections had active SLE (SLEDAI >7).
Conclusions. Cryptococcus neoformans infection accounted for most fatalities in SLE patients with fungal infections in this series. Active lupus disease is probably a risk factor for fungal infection in SLE patients. Notably, low prednisolone doses prior to fungal infection or high prednisolone doses following fungal infection tended to associate with or correlated to fatality, respectively. Therefore, we suggest that different prednisolone doses prescribed at various times impact the incidence of fungal infection and its associated mortality.
KEY WORDS: Systemic lupus erythematosus, Fungal infection, SLEDAI, Prednisolone
Submitted 21 August 2005;
revised version accepted 5 September 2006.
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