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Predictors of major infection in patients following major immunosuppressive therapy – An observational study
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i n d i a n j o u r n a l o f r h e u m a t o l o g y 9 ( 2 0 1 4 ) S 7 eS 6 7
Introduction: Studies shows, SLE patients are more prone to have atherosclerosis and cardiovascular diseases than normal population .Recent studies hypothesize that atherosclerosis has similarities with other inflammatory and autoimmune diseases like SLE. Methods: Our study was designed to evaluate factors associated with the development of atherosclerosis in patients with SLE. As a surrogate measure of atherosclerosis we considered the CIMT evaluated by B mode ultrasound. CIMT value of 0.7mm was considered cut-off. Total 47 patients of SLE were included in study. SPSS (version 14) software program was used for analysis. Result: Mean age was 28.1±7.3years.Increased age (<30yrs vs>30yrs)was associated with raised CIMT (p <0.01) .The mean disease duration of patients with raised and normal CIMT was 71.6±32.5 and 13.5±18.2 months respectively (p<0.01). Correlation of SLEDAI score >10 and increased CIMT was significant (p<0.014). According to NCEP criteria, 27 (57.44%) had dyslipidemia. Raised CIMT was in 13/27(48.1%) of dislipidaemic compared to 1/20 (5%) in non-dislipidaemic patients (p<0. 01).Raised LDL cholesterol and Triglycerides correlates with raised CIMT. Increased CIMT correlates with increased BMI (BMI 23.5±2.8 Vs 25.9±2.2 kg/m2) (p<0.01).Raised CIMT was present in 60% hypertensive as compared to 7.5% non-hypertensive patients (p<0.01). Hypothyroidism was found in 7% patients, all were on thyroid supplements. Raised CIMT was found in 87.5% hypothyroid patients (p<0.01).Patients with higher CIMT were having higher mean cumulative steroid intake of 16.6gms (p<0.01). Conclusion: Age, longer disease duration, SLEDAI score >10, dyslipidaemia, higher BMI, hypertension, increased cumulative steroid dosage and hypothyroidism are independent risk factors for atherosclerosis in lupus patients.
P101. Seroprevelance of antiphospholipid antibody in systemic lupus erythematosus Daisy Doleya, Sanjeeb Kakatia, Lahari Saikiab; aDepartments of Internal Medicine and bMicrobiology, Assam Medical College, Dibrugarh, India Introduction: Systemic Lupus Erythematosus (SLE) is associated with significant morbidity and mortality. Anti-phospholipid antibody positivity further increases these risks due to arterial and/or venous thrombosis and recurrent pregnancy losses. Methods: 70 SLE cases were taken up at a tertiary centre for evaluation of the prevalence of Anti-Phospolipid Antibodies (APLA): anticardiolipin antibody and lupus anticoagulant. The presence of APLA was correlated with the clinical features of SLE. Anticardiolipin (aCL) IgM and IgG antibody were detected by ELISA and Lupus anticoagulant (LA) by DRVVT method. Results: 30 cases (42%) had renal manifestations. ACL IgM was found positive in 13 cases(18%), ACL IgG in 13 cases(18%).Both ACL IgM and ACL IgG was positive in 9 cases(12%). Lupus anticoagulant was positive in 9 cases (12%). In the lupus nephritis group, 8 cases (26%) were positive for either IgM or IgG ACA. In the non-nephritis group, 9 cases (22%) were positive for either IgM or IgG ACA. LA was positive in 5 cases (16%) in the lupus nephritis group and 4 cases (10%) in the non-nephritis group. Conclusion: The prevalence of APLA was 28.6%. In this study both ACA and LA positivity was found slightly higher in lupus nephritis group. Prevalence of ALPA in SLE may be a marker of poorer prognosis unless detected early and managed. This shows the importance of screening of all SLE patients for APLA antibodies.
P102. Predictors of major infection in patients following major immunosuppressive therapy e An observational study C. Srinivasa, I.R. Varaprasad, L. Rajasekhar.; Department of Rheumatology, Nizam's Institute of Medical Sciences, Hyderabad, India Introduction: Rheumatic disease patients receiving immunosuppression frequently develop severe acute, chronic (tuberculosis), and opportunistic infections. Objective: To determine predictors of serious infection in 6 months following treatment with cyclophosphamide (CYC) and pulse methylprednisolone (MP). Methods: Inpatients records of patients admitted in 2013 who received 3 gm MP and monthly CYC over 6 months were screened. SLE patients with no infections (SLEUI), with infections (SLEI) and patients with other rheumatic diseases (ORD, primary vasculitis, dermatomyositis) were compared. Age, SLEDAI, total leukocyte count, renal failure and dsDNA were noted in both SLEUI and SLEI patients. Results: Seventeen major infections were identified among 52 patients (43 SLE, 9 ORD) who received above treatment over 6 months. Mean duration to infection was 51 days. Four patients had tuberculosis, 3 cellulitis, 2 UTI, 2 septicemia, 2 musculoskeletal infections and 1 had pneumonia. Fifteen (34.9%) SLE patients developed infections compared to 2 (22.2%) ORD patients(P¼0.4). Mean age, mean SLEDAI was similar in SLEI (16.5±5.9) and SLEUI (18.07±7.9) (p¼0.3). No patient had diabetes or renal failure. 8 of 15 SLEI patients had leucopenia compared to 3 of 28 SLEUI patients (p¼0.002). Infections resulted in 2 deaths both in SLE. Conclusion: One third of patients receiving major immunosuppression developed infection. Incidence is higher in lupus than other rheumatic diseases. Leucopenia at onset is an important predictor of major infection in lupus. Guidelines on TB and bacterial prophylaxis are needed.
P103. Hypercalcemia e Lymphadenopathy Systemic Lupus Erythematosus(Hl-Sle) Kaushik Rajamania, Kiran Putchakayalab; Wales; bLeighton Hospital, Crewe, UK
a
University Hospital
Introduction: SLE is a chronic autoimmune inflammatory disease. Hypercalcemia in SLE is rare. We report a 25 year old lady with SLE and hypercalcemia. She presented to A&E with complaints of nausea, vomiting, abdominal pain and polyarthralgia. O/e BP 20/ 70.Erythematous maculopapular rash on the dorsum of hands. B/L axillary lymphadenopathy was present, non-tender and firm in consistency. Chest clear, heart sounds normal. Urine dip normal. Bloods. WCC - 8.0 109/L; ANA/Ro/La - þve; IgG - 15.7g/L; Neutrophils - 7.2 109/L; dsDNA e 34; IgM - 0.97 g/L; Lymphocytes - 0.39 109/L; Sm/ RNP/DCT - þve; No paraproteins; ESR - 34mm/hr; Serum ACE normal; Vitamin D - 33.6; Corrected calcium 3.33; C 3 - 0.61; C4 0.09; PTH - <0.3; Imaging; CXR:Normal; CT chest and abdomen/ pelvis: multiple significantly enlarged bilateral axillary lymph nodes with b/l pleural effusion. Axillary lymph node biopsy: lymph node showed follicular hyperplasia and sinus histiocytosis; Bone marrow trephine: Normal; Treatment: With Prednisolone and Hydroxychloroquine, her serum Ca/lymphocyte count reverted to normal with regression in the size of the lymphadenopathy. Conclusion: SLE needs to be considered in patients with hypercalcemia. It may be associated with pleuritis and
i n d i a n j o u r n a l o f r h e u m a t o l o g y 9 ( 2 0 1 4 ) S 7 eS 6 7
Introduction: Studies shows, SLE patients are more prone to have atherosclerosis and cardiovascular diseases than normal population .Recent studies hypothesize that atherosclerosis has similarities with other inflammatory and autoimmune diseases like SLE. Methods: Our study was designed to evaluate factors associated with the development of atherosclerosis in patients with SLE. As a surrogate measure of atherosclerosis we considered the CIMT evaluated by B mode ultrasound. CIMT value of 0.7mm was considered cut-off. Total 47 patients of SLE were included in study. SPSS (version 14) software program was used for analysis. Result: Mean age was 28.1±7.3years.Increased age (<30yrs vs>30yrs)was associated with raised CIMT (p <0.01) .The mean disease duration of patients with raised and normal CIMT was 71.6±32.5 and 13.5±18.2 months respectively (p<0.01). Correlation of SLEDAI score >10 and increased CIMT was significant (p<0.014). According to NCEP criteria, 27 (57.44%) had dyslipidemia. Raised CIMT was in 13/27(48.1%) of dislipidaemic compared to 1/20 (5%) in non-dislipidaemic patients (p<0. 01).Raised LDL cholesterol and Triglycerides correlates with raised CIMT. Increased CIMT correlates with increased BMI (BMI 23.5±2.8 Vs 25.9±2.2 kg/m2) (p<0.01).Raised CIMT was present in 60% hypertensive as compared to 7.5% non-hypertensive patients (p<0.01). Hypothyroidism was found in 7% patients, all were on thyroid supplements. Raised CIMT was found in 87.5% hypothyroid patients (p<0.01).Patients with higher CIMT were having higher mean cumulative steroid intake of 16.6gms (p<0.01). Conclusion: Age, longer disease duration, SLEDAI score >10, dyslipidaemia, higher BMI, hypertension, increased cumulative steroid dosage and hypothyroidism are independent risk factors for atherosclerosis in lupus patients.
P101. Seroprevelance of antiphospholipid antibody in systemic lupus erythematosus Daisy Doleya, Sanjeeb Kakatia, Lahari Saikiab; aDepartments of Internal Medicine and bMicrobiology, Assam Medical College, Dibrugarh, India Introduction: Systemic Lupus Erythematosus (SLE) is associated with significant morbidity and mortality. Anti-phospholipid antibody positivity further increases these risks due to arterial and/or venous thrombosis and recurrent pregnancy losses. Methods: 70 SLE cases were taken up at a tertiary centre for evaluation of the prevalence of Anti-Phospolipid Antibodies (APLA): anticardiolipin antibody and lupus anticoagulant. The presence of APLA was correlated with the clinical features of SLE. Anticardiolipin (aCL) IgM and IgG antibody were detected by ELISA and Lupus anticoagulant (LA) by DRVVT method. Results: 30 cases (42%) had renal manifestations. ACL IgM was found positive in 13 cases(18%), ACL IgG in 13 cases(18%).Both ACL IgM and ACL IgG was positive in 9 cases(12%). Lupus anticoagulant was positive in 9 cases (12%). In the lupus nephritis group, 8 cases (26%) were positive for either IgM or IgG ACA. In the non-nephritis group, 9 cases (22%) were positive for either IgM or IgG ACA. LA was positive in 5 cases (16%) in the lupus nephritis group and 4 cases (10%) in the non-nephritis group. Conclusion: The prevalence of APLA was 28.6%. In this study both ACA and LA positivity was found slightly higher in lupus nephritis group. Prevalence of ALPA in SLE may be a marker of poorer prognosis unless detected early and managed. This shows the importance of screening of all SLE patients for APLA antibodies.
P102. Predictors of major infection in patients following major immunosuppressive therapy e An observational study C. Srinivasa, I.R. Varaprasad, L. Rajasekhar.; Department of Rheumatology, Nizam's Institute of Medical Sciences, Hyderabad, India Introduction: Rheumatic disease patients receiving immunosuppression frequently develop severe acute, chronic (tuberculosis), and opportunistic infections. Objective: To determine predictors of serious infection in 6 months following treatment with cyclophosphamide (CYC) and pulse methylprednisolone (MP). Methods: Inpatients records of patients admitted in 2013 who received 3 gm MP and monthly CYC over 6 months were screened. SLE patients with no infections (SLEUI), with infections (SLEI) and patients with other rheumatic diseases (ORD, primary vasculitis, dermatomyositis) were compared. Age, SLEDAI, total leukocyte count, renal failure and dsDNA were noted in both SLEUI and SLEI patients. Results: Seventeen major infections were identified among 52 patients (43 SLE, 9 ORD) who received above treatment over 6 months. Mean duration to infection was 51 days. Four patients had tuberculosis, 3 cellulitis, 2 UTI, 2 septicemia, 2 musculoskeletal infections and 1 had pneumonia. Fifteen (34.9%) SLE patients developed infections compared to 2 (22.2%) ORD patients(P¼0.4). Mean age, mean SLEDAI was similar in SLEI (16.5±5.9) and SLEUI (18.07±7.9) (p¼0.3). No patient had diabetes or renal failure. 8 of 15 SLEI patients had leucopenia compared to 3 of 28 SLEUI patients (p¼0.002). Infections resulted in 2 deaths both in SLE. Conclusion: One third of patients receiving major immunosuppression developed infection. Incidence is higher in lupus than other rheumatic diseases. Leucopenia at onset is an important predictor of major infection in lupus. Guidelines on TB and bacterial prophylaxis are needed.
P103. Hypercalcemia e Lymphadenopathy Systemic Lupus Erythematosus(Hl-Sle) Kaushik Rajamania, Kiran Putchakayalab; Wales; bLeighton Hospital, Crewe, UK
a
University Hospital
Introduction: SLE is a chronic autoimmune inflammatory disease. Hypercalcemia in SLE is rare. We report a 25 year old lady with SLE and hypercalcemia. She presented to A&E with complaints of nausea, vomiting, abdominal pain and polyarthralgia. O/e BP 20/ 70.Erythematous maculopapular rash on the dorsum of hands. B/L axillary lymphadenopathy was present, non-tender and firm in consistency. Chest clear, heart sounds normal. Urine dip normal. Bloods. WCC - 8.0 109/L; ANA/Ro/La - þve; IgG - 15.7g/L; Neutrophils - 7.2 109/L; dsDNA e 34; IgM - 0.97 g/L; Lymphocytes - 0.39 109/L; Sm/ RNP/DCT - þve; No paraproteins; ESR - 34mm/hr; Serum ACE normal; Vitamin D - 33.6; Corrected calcium 3.33; C 3 - 0.61; C4 0.09; PTH - <0.3; Imaging; CXR:Normal; CT chest and abdomen/ pelvis: multiple significantly enlarged bilateral axillary lymph nodes with b/l pleural effusion. Axillary lymph node biopsy: lymph node showed follicular hyperplasia and sinus histiocytosis; Bone marrow trephine: Normal; Treatment: With Prednisolone and Hydroxychloroquine, her serum Ca/lymphocyte count reverted to normal with regression in the size of the lymphadenopathy. Conclusion: SLE needs to be considered in patients with hypercalcemia. It may be associated with pleuritis and