Infections in Systemic Autoimmune Diseases

Risk Factors and Management

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• Publisher: Elsevier
• Year: 2020
• ISBN:
  9780444642189
• Topic: Medicine
• Subtopic: Immunology

Infections in Systemic Autoimmune Diseases: Risk Factors and Management, Volume Sixteen describes the state-of-the-art of the risk factors and management treating the most common systemic autoimmune diseases (SADS). This updated volume consists of an introductory chapter that provides a brief overview of what different types of infectious diseases exist, followed by eight chapters detailing risk factors, guidelines and recommendations per different disease and bacterial infections. International in scope, the list of more than 20 contributors from Europa and America reads like a who's who of clinical researchers in the field.

• Written by leading international clinical/surgical and scientific experts on Infection problems in systemic autoimmune diseases
• Provides a practical guide to the safer treatment of infections in patients with autoimmune diseases
• Includes a number of problems and recommendation that cannot be found in other books
• Designed as a 'guide to clinical practice' for management and risk interventions required by patients with SAD's

Chapter 1

Bacterial infections in the lungs of patients with systemic autoimmune diseases

Ilaria Di Cataldo ¹ , Alfio Proietto ¹ , Irene Coppolino ¹ , Mario Francesco Cannavò ¹ , Attilio Cotroneo ¹ , Federica Lo Bello ¹ , Paolo Ruggeri ¹ , Ian M. Adcock ² and Gaetano Caramori ^{1 , ∗ 1} Pneumologia, Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini Morfologiche e Funzionali (BIOMORF), Università di Messina, Messina, Italy ² Airway Disease Section, National Heart and Lung Institute, Imperial College, London, United Kingdom
^∗ Corresponding Author: E-mail: [email protected]

Abstract

In patients with systemic autoimmune diseases (such as systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, Sjogren syndrome, polymyositis/dermatomyositis, and antineutrophil cytoplasmatic autoantibody-related vasculitis), pneumonia is one of the most common complications and an important cause of hospitalization, morbidity, and mortality.

These patients may be more susceptible to bacterial infection of the lungs because of impaired host defenses associated with the disease itself (immune system alterations and organ damage) and the effects on the immune response to bacteria of concomitant immunosuppressive therapy.

Cigarette smoking cessation and vaccination against Streptococcus pneumoniae and Haemophilus influenzae type B are recommended.

There are no standardized protocols for the diagnosis, differential diagnosis, and the treatment of pneumonia in these patients. Current best practice is to follow national and international guidelines on community-acquired pneumonia, hospital-acquired pneumonia, aspiration pneumonia, and pneumonia in specific cases of immunocompromission, even though the precise causative pathogen will be unknown.

Keywords

Bacterial infections; Immunosuppressive therapy; Monoclonal antibodies; Pneumonia; Rheumatoid arthritis; Systemic autoimmune disease; Systemic glucocorticoids; Systemic lupus erythematosus; Systemic sclerosis

1. Introduction

We will review here the literature on the topic of bacterial infections of the lungs in adult patients with systemic autoimmune diseases. We will not cover here mycobacterial lung infections.

2. Increased risk of bacterial infections in the lungs of patients with systemic autoimmune diseases

In patients with systemic autoimmune diseases (such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), systemic sclerosis (SSc), Sjogren syndrome, polymyositis/dermatomyositis (PM/DM), and antineutrophil cytoplasmic autoantibody (ANCA)-related vasculitis), pneumonia is one of the most common complications and an important cause of hospitalization, morbidity, and mortality.

For these patients, the risk of developing lower respiratory tract infections is increased compared with the general population [1].

For example, lung disease is second only to infection as the most common cause of death in patients with RA [2] and mortality as respiratory infections in these patients are 2–5 times higher than that in general population; for this reason, hospital admission of RA patients is doubled [3]. Patients with RA are at twice the risk of developing a bacterial infection of the lungs compared with the general population [1]. Despite the severity of pneumonia in RA patients being similar to that observed in non-RA patients, the mortality due to pneumonia is significantly increased in RA patients [4].

The most frequent bacteria causing pneumonia in RA patients are Streptococcus pneumoniae, Pseudomonas aeruginosa, Haemophilus influenzae, and Mycoplasma pneumoniae [4]. Recent metagenomic evidence in chronic obstructive pulmonary disease suggests that the pathological Streptococcus species may be pseudopneumoniae rather than pneumoniae per se [5].

In SLE patients, pulmonary infections, including bacterial infections, are identified in 75% of cases and cause 30%–50% of all deaths [6].

SLE patients have an increased susceptibility to bacterial pulmonary infections caused by S. pneumoniae, Staphylococcus aureus, and Pseudomonas aeruginosa [6–11].

Lung infections caused by Nocardia have been described in SLE patients, but mainly in immunocompromised patients following treatment with systemic glucocorticoids (GCs) [12].

Aspiration pneumonia occurs in 15%–20% of PM/DM patients and is often caused by S. pneumoniae and H. influenzae, and by Staphylococcus aureus and Pseudomonas aeruginosa in patients with severe comorbidities [2,7,8,13–16].

The patients with ANCA-associated vasculitis are more susceptible to bacterial infections in the lungs, which are one of the most common causes of death and morbidity, particularly in patients undergoing immunosuppressive therapy. The most common bacterial infections of the lungs of these patients are S. pneumoniae, H. influenzae, Pseudomonas aeruginosa, Staphylococcus aureus, and Klebsiella pneumoniae [17,18].

3. Pathogenesis of the increased susceptibility to bacterial infections in the lungs of patients with systemic autoimmune diseases

Patients with systemic autoimmune diseases may be more susceptible to bacterial infection of the lungs because of impaired host defenses associated with the disease itself and/or the effects on the immune response to bacteria of concomitant immunosuppressive therapy [11].

Impaired host defenses against bacterial infections of the lungs associated with the disease itself.

There are many potential disease–induced causes of immunodeficiency in patients with systemic autoimmune diseases which may increase their susceptibility to develop bacterial infections of the lungs.

For example, in SLE, there is a deficiency of the complement proteins C1q, C1r, C1s, and C4 and rarely C2 and C3 along with a reduced number of their receptors [19]. Immunoglobulin (Ig) synthesis and the number of blood B cells and T CD4 cells is also decreased together with impaired leukocyt...

Table of contents

• Cover image
• Title page
• Table of Contents
• Handbook of Systemic Autoimmune Diseases
• Copyright
• Dedication
• Contributors
• Preface
• Chapter 1. Bacterial infections in the lungs of patients with systemic autoimmune diseases
• Chapter 2. Invasive fungal diseases in patients with rheumatic diseases
• Chapter 3. Urinary tract infection and autoimmune diseases
• Chapter 4. Viral hepatitis
• Chapter 5. Mycobacteria and immunosuppression
• Chapter 6. The immunosuppressed traveler: infection risks with autoimmunity and immunosuppression, vaccinations, and general travel advice
• Chapter 7. Infections in systemic autoimmune diseases
• Chapter 8. Bone and joint bacterial infections in patients with rheumatoid arthritis
• Chapter 9. Risk/benefit management in the infectious phase in systemic autoimmune rheumatic diseases
• Index