Systemic Lupus Erythematosus Infection Research Articles

P31 Navigating complex infections in systemic lupus erythematosus: a lupus flare complicated with neutropenic sepsis and a rare fungal infection by Magnusiomyces clavatus

P31 Navigating complex infections in systemic lupus erythematosus: a lupus flare complicated with neutropenic sepsis and a rare fungal infection by Magnusiomyces clavatus

Infection versus disease activity in systemic lupus erythematosus patients with fever

Backgroundto detect the role of procalcitonin, erythrocyte sedimentation rate to c-reactive protein (ESR/CRP) ratio, neutrophils-to-lymphocyte ratio (NLR), and platelets-to-lymphocyte ratio (PLR) in the diagnosis of infection in systemic lupus erythematosus (SLE) patients with fever, their diagnostic value to differentiate between infection and disease activity, and their correlation with disease activity.MethodsForty SLE patients and forty healthy control cases were included in the study. Disease activity was assessed by the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2 K), and quality of life was assessed by Lupus QoL. A bacterial infection was detected by clinical symptoms and positive culture results. Laboratory tests were done for all patients and controls: complete blood count (CBC), ESR, CRP, and procalcitonin (PCT). NLR, PLR, and ESR/CRP ratios were calculated.ResultsThere was a statistically significant difference between infected SLE patients and non-infected SLE patients regarding PCT (p < 0.001), ESR (p = 0.002), CRP (p = 0.005), ESR/CRP ratio (0.002), and NLR (p = 0.023). PCT, ESR, CRP, and NLR were positively correlated with the presence of infection in SLE patients, while the ESR/CRP ratio was negatively correlated. There was no significant correlation with the SLEDAI-2 K score. Logistic regression analysis revealed that PCT was the best significant predictor of infection (OR 224.37, 95% CI 8.94–5631.35). PCT was a good predictor of infection, with a cut-off value of 0.90 ng/ml, which gave the best combination of sensitivity (84.62%) and specificity (85.71%).ConclusionPCT, ESR/CRP ratio, and NLR provide good diagnostic markers for the diagnosis of infection and can distinguish between infection and disease flare in SLE patients with fever.

Safety and tolerance of vaccines against SARS-CoV-2 infection in systemic lupus erythematosus: results from the COVAD study.

To determine COVID-19 vaccine-related adverse events (AEs) in the seven-day post-vaccination period in patients with SLE vs autoimmune rheumatic diseases (AIRDs), non-rheumatic autoimmune diseases (nrAIDs), and healthy controls (HC). Data were captured through the COVID-19 Vaccination in Autoimmune Diseases (COVAD) questionnaire (March-December 2021). Multivariable regression models accounted for age, gender, ethnicity, vaccine type and background treatment. Among 9462 complete respondents, 583 (6.2%) were SLE patients (mean age: 40.1 years; 94.5% females; 40.5% Asian; 42.9% Pfizer-recipients). Minor AEs were reported by 83.0% of SLE patients, major by 2.6%, hospitalization by 0.2%. AE and hospitalization frequencies were similar between patients with active and inactive SLE. Rashes were more frequent in SLE patients vs HC (OR; 95% CI: 1.2; 1.0, 1.5), chills less frequent in SLE vs AIRDs (0.6; 0.4, 0.8) and nrAIDs (0.5; 0.3, 0.8), and fatigue less frequent in SLE vs nrAIDs (0.6; 0.4, 0.9). Pfizer-recipients reported higher overall AE (2.2; 1.1, 4.2) and injection site pain (2.9; 1.6, 5.0) frequencies than recipients of other vaccines, Oxford/AstraZeneca-recipients more body ache, fever, chills (OR: 2.5, 3.0), Moderna-recipients more body ache, fever, chills, rashes (OR: 2.6, 4.3). Hospitalization frequencies were similar across vaccine types. AE frequencies were similar across treatment groups, although chills were less frequent in antimalarial users vs non-users (0.5; 0.3, 0.9). While COVID-19 vaccination-related AEs were reported by four-fifths of SLE patients, those were mostly minor and comparable to AEs reported by healthy individuals, providing reassurance regarding COVID-19 vaccination safety in SLE.

Should asymptomatic bacteriuria be treated in lupus nephritis?

The risk of infection in systemic lupus erythematosus (SLE) is associated with factors related to disease activity and immunosuppressive treatment. Recently, the persistence of asymptomatic bacteriuria (ASB) has been proposed as an environmental trigger for SLE and its flares, raising the question whether it should be treated systematically to reduce the risk of infection. To our knowledge, there is limited evidence on the screening and treatment of ASB in SLE. The objective is to analyze the occurrence of infection and flare in patients with lupus nephritis with and without ASB. A cross-sectional study of a cohort of patients with lupus nephritis during induction therapy with high-dose cyclophosphamide regimen was carried out between January 2018 and 2020, with a total of 37 patients investigated. Urine and blood samples from the two groups (with ASB and without ASB) where taken before the administration of cyclophosphamide. From the sampled 37 patients, 19 (51.4%) had ASB and 18 (48.6%) without ASB; both groups were well balanced in their demographics and clinical characteristics. No statistically significant association was found between the presence of ASB and the systemic lupus erythematosus disease activity index score (p = 0.604), and neither with the 24-h urine protein and leukocyte count (p > 0.177). Urinary tract infection occurred in 5.3% (1) of the patients with ASB, while 5.6% (1) of the patients in the group without ASB presented the infection, and the RR was 0.944 (0.06, 16.33) 95% CI; in addition, no statistically significant association was found between the presence of ASB and the occurrence of infection (p = 1,000). Our study did not find a statistically significant association of ASB with the occurrence of infection or disease activity. Further studies need it to clarify this, since treatment of ASB has been recognized as an important contributor to inappropriate antimicrobial use, which promotes emergence of antimicrobial resistance.

Infections in systemic lupus erythematosus: A study of incidence and risk factors in 100 patients from western India

Aim: The present study was conducted to evaluate the incidence and characteristics of infections in patients of systemic lupus erythematosus (SLE) and determine the risk factors for infection.Materials and Methods: This is a prospective, observational study carried out at a single-center, tertiary care hospital. The study included all adult SLE patients diagnosed as per the revised American College of Rheumatology (ACR) criteria from January 2015 to October 2019. Episodes of infection and pathogens isolated were recorded.Results: A total of 100 patients with SLE were evaluated (94 females and 6 males). Forty-seven (47%) patients suffered from 54 episodes of infection. Urinary tract infections were most common (31.48%), followed by skin and mucous membrane (27.78%). Escherichia coli (E. coli) was the most common organism isolated in 9 (16.8%) cases. Tuberculosis was seen in 6 (11.1%) patients. Forty-three (79.6%) patients had a SLE disease activity index score of more than 5 at the time of infection. Significant risk factors for infection included use of prednisolone, prednisolone dose higher than 10 mg, use of cyclophosphamide within the preceding 3 months of infections, use of other immunosuppressive agents, and leukopenia. Renal lupus and presence of comorbidities did not have a significant association with occurrence of infections. The relative risk of infections in SLE patients was 4.7 compared to non SLE controls.Conclusion: Patients of SLE are at increased risk for various infections. Management of SLE needs vigilance for infection and judicious use of immunosuppressive drugs.

Predictors of Serious Infection in Systemic Lupus Erythematosus: A Time-to-Event Analysis

Predictors of Serious Infection in Systemic Lupus Erythematosus: A Time-to-Event Analysis

Development of Prediction Models for New Integrated Models and a Bioscore System to Identify Bacterial Infections in Systemic Lupus Erythematosus.

ObjectivesDistinguishing flares from bacterial infections in systemic lupus erythematosus (SLE) patients remains a challenge. This study aimed to build a model, using multiple blood cells and plasma indicators, to improve the identification of bacterial infections in SLE.DesignBuilding PLS-DA/OPLS-DA models and a bioscore system to distinguish bacterial infections from lupus flares in SLE.SettingDepartment of Rheumatology of the Second Hospital of Shanxi Medical University.ParticipantsSLE patients with flares (n = 142) or bacterial infections (n = 106) were recruited in this retrospective study.OutcomeThe peripheral blood of these patients was collected by the experimenter to measure the levels of routine examination indicators, immune cells, and cytokines. PLS-DA/OPLS-DA models and a bioscore system were established.ResultsBoth PLS-DA (R2Y = 0.953, Q2 = 0.931) and OPLS-DA (R2Y = 0.953, Q2 = 0.942) models could clearly identify bacterial infections in SLE. The white blood cell (WBC), neutrophile granulocyte (NEUT), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), procalcitonin (PCT), interleukin-6 (IL-6), IL-10, interferon-γ (IFN-γ), and tumor necrosis factor α (TNF-α) levels were significantly higher in bacteria-infected patients, while regulatory T (Treg) cells obviously decreased. A multivariate analysis using the above 10 dichotomized indicators, based on the cut-off value of their respective ROC curve, was established to screen out the independent predictors and calculate their weights to build a bioscore system, which exhibited a strong diagnosis ability (AUC = 0.842, 95% CI 0.794–0.891). The bioscore system showed that 0 and 100% of SLE patients with scores of 0 and 8–10, respectively, were infected with bacteria. The higher the score, the greater the likelihood of bacterial infections in SLE.ConclusionsThe PLS-DA/OPLS-DA models, including the above biomarkers, showed a strong predictive ability for bacterial infections in SLE. Combining WBC, NEUT, CRP, PCT, IL-6, and IFN-γ in a bioscore system may result in faster prediction of bacterial infections in SLE and may guide toward a more appropriate, timely treatment for SLE.

Predictive models of infection in patients with systemic lupus erythematosus: A systematic literature review.

Having reliable predictive models of prognosis/the risk of infection in systemic lupus erythematosus (SLE) patients would allow this problem to be addressed on an individual basis to study and implement possible preventive or therapeutic interventions. To identify and analyze all predictive models of prognosis/the risk of infection in patients with SLE that exist in medical literature. A structured search in PubMed, Embase, and LILACS databases was carried out until May 9, 2020. In addition, a search for abstracts in the American Congress of Rheumatology (ACR) and European League Against Rheumatism (EULAR) annual meetings' archives published over the past eight years was also conducted. Studies on developing, validating or updating predictive prognostic models carried out in patients with SLE, in which the outcome to be predicted is some type of infection, that were generated in any clinical context and with any time horizon were included. There were no restrictions on language, date, or status of the publication. To carry out the systematic review, the CHARMS (Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies) guideline recommendations were followed. The PROBAST tool (A Tool to Assess the Risk of Bias and Applicability of Prediction Model Studies) was used to assess the risk of bias and the applicability of each model. We identified four models of infection prognosis in patients with SLE. Mostly, there were very few events per candidate predictor. In addition, to construct the models, an initial selection was made based on univariate analyses with no contraction of the estimated coefficients being carried out. This suggests that the proposed models have a high probability of overfitting and being optimistic. To date, very few prognostic models have been published on the infection of SLE patients. These models are very heterogeneous and are rated as having a high risk of bias and methodological weaknesses. Despite the widespread recognition of the frequency and severity of infections in SLE patients, there is no reliable predictive prognostic model that facilitates the study and implementation of personalized preventive or therapeutic measures.Protocol registration number: PROSPERO CRD42020171638.

Epidemiology and risk of invasive fungal infections in systemic lupus erythematosus: a nationwide population-based cohort study.

Introduction:Infections are a leading cause of mortality in patients with systemic lupus erythematosus (SLE). Among various infections, invasive fungal infections (IFIs) have a particularly high mortality rate; however, studies examining IFIs in patients with SLE are limited.Methods:Patients diagnosed as having SLE between 1997 and 2012 were enrolled from Taiwan’s National Health Insurance Research Database along with age- and sex-matched non-SLE controls at a ratio of 1:10. IFIs were identified based on International Classification of Diseases, Ninth Revision, Clinical Modification codes and validated by the prescriptions of systemic antifungal agents. The incidence rate (IR), incidence rate ratio (IRR), and all-cause mortality rate of IFIs and its subtypes were analyzed. A Cox multivariate regression model with time-dependent covariates was applied to analyze independent risk factors for IFIs.Results:A total of 24,541 patients with SLE and 245,410 non-SLE controls were included. We observed 445 IFI episodes in the SLE cohort, with an all-cause mortality rate of 26.7%. Candida spp. (52.8%) was the most common pathogen, followed by Cryptococcus spp. (18.2%) and Aspergillus spp. (18.2%). The IR of IFIs in the SLE cohort was 20.83 per 10,000 person-years, with an IRR of 11.1 [95% confidence interval (CI): 9.8–12.6] relative to the non-SLE controls. Juvenile patients with SLE aged ⩽18 years had the highest IRR of 47.2 (95% CI: 26.9–86.8). Intravenous steroid therapy administered within 60 days (hazard ratio: 29.11, 95% CI: 23.30–36.37) was the most critical risk factor for overall IFIs and each of the three major fungal pathogens. Distinct risk factors were found among different IFI subtypes.Conclusion:Patients with SLE had a higher risk of IFIs, especially juvenile patients. Intravenous steroid therapy is the most critical risk factor for IFIs. This study provides crucial information for the risk stratification of IFIs in SLE.Plain Language SummariesPatients with systemic lupus erythematosus and physicians treating this patient group should be aware of the risk of invasive fungal infections.Invasive fungal infections (IFIs) are a severe complication with a high mortality rate among patients with systemic lupus erythematosus (SLE); however, studies on this topic are scant. We performed a nationwide population-based study in Taiwan to estimate the incidence and mortality of and risk factors for IFIs. We found an incidence rate of 20.83 per 10,000 person-years for IFIs, with a mortality rate of 26.7%. Juvenile patients aged ⩽18 years had the highest relative risk of IFIs. Although candidiasis was the most common IFI, cryptococcosis and aspergillosis should be concerned in juvenile patients as well. Intravenous steroid therapy was the most critical risk factor for all IFIs, and different immunosuppressive agents posed different risks in patients for acquiring certain fungal pathogens.Our findings provide pivotal epidemiological information and indicate risk factors for IFIs in patients with SLE. Age and exposure to specific immunosuppressants and steroids might help predict the risk of IFIs. Because the manifestation of these infections is sometimes indistinguishable from a lupus flare, physicians should be aware of this fatal complication, especially when patients are not responsive to immunosuppressive therapy. Early recognition, implication of diagnostic tools, and empirical antimicrobial agents can be the key to treating patients with IFIs. Additional studies are required to develop a risk management program for patients with SLE.

Laboratory-confirmed bloodstream infection in systemic lupus erythematosus: Risk profiling and short-term mortality.

To delineate laboratory-confirmed bloodstream infection (LCBI), analyze risk factors for its occurrence and predictors for its short-term mortality in systemic lupus erythematosus (SLE) patients.Methods A single center, retrospective, case-controlled study was performed in 159 SLE patients (2013-2019) to identify risk factors of LCBI by comparing patients with LCBI (n = 39) to those without infection (n = 120). The predictors associated with 30-day mortality in LCBI patients were also analyzed. Altogether 40 bacteria strains were isolated in 39 LCBI patients with a predominance of the gram-negative bacilli (24 strains, 60.0%). Escherichia coli and Staphylococcus aureus were the leading Gram-negative and Gram-positive microorganisms, respectively. Occurrence of LCBI was independently predicted by: SLE disease duration >4 years, SLEDAI score >4 points, glucocorticoids dose >7.5 mg/d and the previous or concomitant occurrence of autoimmune hemolytic anemia (AIHA) or thrombotic microangiopathy (TMA). Based on the identified risk factors, we developed a matrix model for the risk of future LCBI. The 30-day mortality (39 cases) was 23.1% and healthcare-associated LCBI was a predictor for 30-day mortality in SLE patients compared with community-acquired LCBI. Longer duration, higher disease activity and glucocorticoids dose, and occurrence of AIHA or TMA were risk factors of LCBI in SLE and its poor short-term prognosis may attribute to healthcare-associated LCBI.

Rheumatic disease and COVID-19: initial data from the COVID-19 Global Rheumatology Alliance provider registries.

Author(s): Gianfrancesco, Milena A; Hyrich, Kimme L; Gossec, Laure; Strangfeld, Anja; Carmona, Loreto; Mateus, Elsa F; Sufka, Paul; Grainger, Rebecca; Wallace, Zachary; Bhana, Suleman; Sirotich, Emily; Liew, Jean; Hausmann, Jonathan S; Costello, Wendy; Robinson, Philip; Machado, Pedro M; Yazdany, Jinoos; COVID-19 Global Rheumatology Alliance Steering Committee

Occurrence, predictors and outcome of infections at three months in hospitalized patients with SLE: A prospective study from Southern India.

Prospective data on infections in systemic lupus erythematosus (SLE) from India are scarce. We studied the frequency and predictors of infections in hospitalized SLE patients. All data on infections were prospectively recorded. During the study period, 212 SLE patients (91% women) were hospitalised. Sixty-three (29.7%) had infections. The most common infections were pneumonia, skin and soft-tissue infections and urinary-tract infections. Mortality was higher in the infection group compared to the no infection group (11.1% vs. 0.7%; p=0.01). At three months, 10/63 developed another episode of infection. On logistic regression, the predictors of infection were fever [odds ratio (OR) = 4.17], vasculitis (OR = 2.64), thrombocytopaenia (OR = 3.59), presence of co-morbidities (OR = 3.59) and duration of hospital stay &gt;11 days (OR = 3.55); p&lt;0.001 for all. High-sensitivity CRP (hsCRP) and procalcitonin were measured in 95 patients. hsCRP was significantly higher in the infection group compared to the no infection group (median 27 vs. 6.5 mg/L; p&lt;0.001). Procalcitonin was similar in both groups. A hsCRP of 11.5 mg/L had a sensitivity of 66.7% and specificity of 72.9% to diagnose infection. To conclude, 29.7% of Indian SLE patients who are hospitalized have infections, resulting in a significantly increased duration of hospital stay. The presence of fever and co-morbidities are predictors of infection. The role of high hsCRP to support the diagnosis of infection in SLE is once again confirmed.

Risk factors for herpes zoster infection among Filipinos with systemic lupus erythematosus

To identify clinical risk factors associated with herpes zoster (HZ) infections in systemic lupus erythematosus (SLE). A case-control study of HZ infection was performed in SLE patients seen at the University of Santo Tomas Lupus Clinics from 2009-2014. Cases were matched 1:2 to SLE controls without HZ infection for age, sex, and disease duration. Clinical characteristics, SLE disease activity, and immunosuppressive use were compared. Sixty-five SLE patients (61, 93.8% female) who developed HZ were matched with 130 SLE patients without HZ. Mean age was 36.75years (±1.35; P=1.00) for the case group; mean SLE disease duration at first HZ infection was 6.1years (±3.3; P = .919). Four patients had more than 1 episode of HZ. There was localized HZ in 63/65 (97%), and 2 (3%) disseminated HZ infections. The case group received higher doses of prednisone 64/65 (P=.012), mean prednisone dose 18.62mg/d (±1.48, P<.001) and more were exposed to cyclophosphamide (Cyc) (19/65; P<.001) compared to the control group's mean prednisone dose of 11.73mg/d (±1.16); there was Cyc use in 7/130 patients. Cyc in addition to mycophenolate mofetil (MMF) use among lupus nephritis patients conferred the highest risk for HZ infection occurrence. Hydroxychloroquine (HCQ) use reduced the risk for HZ by 87% (adjusted odds ratio 0.13, P=.003). Immunosuppressives and corticosteroid use are risk factors associated with the development of HZ in SLE. The risk for HZ increases among patients given intravenous Cyc and MMF for lupus nephritis. SLE disease activity did not show a direct association with HZ occurrence. HCQ use appeared to have a protective role against HZ infection.

Risk of severe herpes simplex virus infection in systemic lupus erythematosus: analysis of epidemiology and risk factors analysis in Taiwan

ObjectivePatients with systemic lupus erythematosus (SLE) are susceptible to herpes simplex virus (HSV) infection, which occasionally leads to severe complications including meningoencephalitis and keratitis. However, few attempts to analyse the...

Suppurative Cervical Adenitis Due to Streptococcus pneumoniae Infection in Systemic Lupus Erythematosus.

Suppurative Cervical Adenitis Due to Streptococcus pneumoniae Infection in Systemic Lupus Erythematosus.

Utility of neutrophil-to-lymphocyte ratio plus C-reactive protein for infection in systemic lupus erythematosus.

To analyze the utility of neutrophil-to-lymphocyte ratio (NLR) plus C-reactive protein (CRP) to differentiate between infection and active disease in patients with SLE. A cross-sectional study of a cohort of patients with SLE was carried out. Blood samples from four groups (patients without infection or active disease, patients with infection, patients with active disease, and patients with both infection and active disease) before therapeutic interventions were analyzed. We excluded patients with current malignancy, pregnancy, ischemic heart disease or use of antimicrobials during previous 7 days. Hematological cell count, CRP and cultures were obtained. We constructed receiver operating characteristic curves; sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated. Forty patients were included. NLR cut-off ≥6.3 had sensitivity 70%, specificity 85%, PPV 83% and NPV 74% to detect patients with non-viral infections. A CRP cut-off ≥7.5 mg/L had sensitivity 90%, specificity 75%, PPV 78% and NPV 88% to detect infections regardless of SLE activity. Combination of CRP plus NLR improves the specificity to 90% and PPV to 88%. Excluding the group with both infection and active disease, CRP plus NLR expands specificity to 95% and NPV to 90%. In our experience, levels of CRP, particularly CRP plus NLR, were useful in differentiating patients with SLE from those with suspected non-viral infection regardless of the activity of the disease.

Procalcitonin and C-reactive protein as markers of infection in systemic lupus erythematosus: the controversy continues.

The objective of this paper is to investigate the utility of serum procalcitonin (PCT) and C-reactive protein (CRP) as markers of infection in systemic lupus erythematosus (SLE) patients. Sixty-nine SLE patients with symptoms and signs of infection proved by culture and/or a favorable response to antibiotics and 69 SLE patients without infection were included. Serum PCT and plasma high-sensitivity CRP were assessed by an enzyme-linked immunosorbent assay. SLE patients with infection had a significantly higher level of CRP than those without infection ((median (IQR) 104.5 (25.5-100.9) and 10.3 (5.4-23.1) mg/l, respectively), p<0.001). Serum PCT could not differentiate SLE patients with or without bacterial infection in this study, while the utility of CRP as a marker of infection has been confirmed.

Severe infections in systemic lupus erythematosus: disease pattern and predictors of infection-related mortality

Infection is a major cause of morbidity and mortality among patients with systemic lupus erythematosus (SLE). To describe the pattern of serious infections in patients with SLE and to identify the predictors of infection-related mortality among SLE patients with serious infections, we prospectively studied all SLE patients who were hospitalized with infections in Sarawak General Hospital during 2011-2015. Demographic data, clinical features, and outcomes were collected. Cox regression analysis was carried out to determine the independent predictors of infection-related mortality. There were a total of 125 patients with 187 episodes of serious infections. Our patients were of multiethnic origins with female predominance (89.6%). Their mean age was 33.4 ± 14.2years. The patients had a mean disease duration of 66.8 ± 74.0months. The most common site of infection was pulmonary (37.9%), followed by septicemia (22.5%). Gram-negative organisms (38.2%) were the predominant isolates within the cohort. There were 21 deaths (11.2%) during the study period. Independent predictors of infection-related mortality among our cohort of SLE patients were flare of SLE (HR 3.98, CI 1.30-12.21) and the presence of bacteremia (HR 2.54, CI 0.98-6.59). Hydroxychloroquine was protective of mortality from serious infections (HR 9.26, CI 3.40-25.64). Pneumonia and Gram-negative organisms were the predominant pattern of infection in our SLE cohort. The presence of flare of SLE and bacteremia were independent prognostic predictors of infection-related mortality, whereas hydroxychloroquine was protective of infection-related mortality among SLE patients with serious infections.

Does erythrocyte sedimentation rate reflect and discriminate flare from infection in systemic lupus erythematosus? Correlation with clinical and laboratory parameters of disease activity.

To examine disease activity parameters in patients with systemic lupus erythematosus (SLE) experiencing flare, infection, both, or neither condition, focusing on erythrocyte sedimentation rate (ESR). This study is a retrospective analysis of 371 consecutive inpatient SLE cases from 2006 to 2015. Cases were classified as flare (n = 147), infection (n = 48), both (n = 23), or neither (n = 135). ESR levels were correlated to C-reactive protein (CRP), ferritin, anti-dsDNA antibodies, complement C3 reduction, serositis, and erythrocyturia with proteinuria (Pearson's correlation). ESR levels were related to an age- and gender-adapted cut-off value (ESRp). We analyzed mean values of age, ESR, ESRp, CRP, ferritin and distribution of anti-dsDNA antibodies, C3 reduction, serositis, and erythrocyturia with proteinuria. Sensitivity and specificity were calculated via receiver operating characteristic or two-by-two table. Association of parameters with disease activity and infection was tested via two-sided chi square test. ESR correlated moderately with CRP in cases with flare and/or infection (r = 0.505-0.586). While ESR and CRP were normal in remission, mean values overlapped in cases with flare, infection, or both. ESRp was higher in flare than in infection (p = 0.048). ESR lost association to activity in infected cases, CRP to infection in flaring cases. ESRp, serositis, and anti-dsDNA antibodies were related to disease activity regardless of infections. Anti-dsDNA antibodies were most sensitive for detecting flares (74%), while serositis, proteinuria with erythrocyturia, anti-dsDNA antibodies, C3 reduction, and ESRp values ≥ 2 were most specific. ESR levels were raised by flares, infections, and age; adapting them to age and gender increased their diagnostic value. Obtaining several parameters remains necessary to differentiate flare from infection.

Infection in systemic lupus erythematosus, similarities, and differences with lupus flare.

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with diverse manifestations, and its pathogenesis is unclear and complicated. Infection and SLE are similar in that they both cause inf lammatory reactions in the immune system; however, one functions to protect the body, whereas the other is activated to damage the body. Infection is known as one of the common trigger factors for SLE; there are a number of reports on infectious agents that provoke autoimmune response. Several viruses, bacteria, and protozoa were revealed to cause immune dysfunction by molecular mimicry, epitope spreading, and bystander activation. In contrast, certain pathogens were revealed to protect from immune dysregulation. Infection can be threatening to patients with SLE who have a compromised immune system, and it is regarded as one of the common causes of mortality in SLE. A clinical distinction between infection and lupus f lare up is required when patients with SLE present fevers. With a close-up assessment of symptoms and physical examination, C-reactive protein and disease activity markers play a major role in differentiating the different disease conditions. Vaccination is necessary because protection against infection is important in patients with SLE.