Fever in Lupus. 21 st April 2014

Transcription

1 Fever in Lupus 21 st April 2014

2 Fever in lupus Cause of fever N= 487 % SLE fever Infection in SLE Active SLE and infection Tumor fever Miscellaneous 4 0.8

3 Crucial Question Infection or SLE or both? Opposite therapy Fatal sepsis can result with use of persistent high dose steroid in infection fever

4 Significant fever A documented temperature > 100F or 37.5C for at least 3 days

5 Define SLE fever No infection identified Diagnosis of Exclusion Follow up is must Features of active SLE Suppressed with hike in steroid No evidence of infection over next 2 weeks Physical examination and Investigations Decision may take a single OPD visit to 2 weeks

6 Case-1 F/20 Presenting complaints Fever from 3 months Cough and multiple joint pains from 2 weeks Symptoms started with cervical lymphadenopathy 8 months back FNAC s/o tuberculosis (no report available) Started on ATT but lymphnodes increased in number

7 Course After 5 months started having high grade fever associated with cough Fall in hb to 4 gm/dl 4 units PRBC Multiple small and large joint pain, swelling and EMS 1 hour 2 nd episode of fall in hb 2 unit of PRBC Reddish malar rash from 2 weeks USG abdomen Hepato-splenomegaly with multiple echogenic foci Admitted in pulmonary department d/t bilateral consolidation with pleural effusion

8 Course CT thorax showed Bilateral lower lobe and right middle lobe consolidation with b/l pleural effusion Treated with antibiotics * 3days no response By that time, ANA 4+ homogenous 1:160, Anti-ds DNA >300 IU/ml, C mg/dl, C mg/dl, TLC 3400, PCT ng/m, CRP 0.89 mg/dl, ESR 120 mm at 1 hr, Blood culture sterile

9 Transfer Started on 1 mg/kg prednisolone with antibiotic cover due to consolidation Repeat CRP 0.89 mg/dl, TLC repeated low, blood and urine culture negative Her symptoms improved, arthritis relieved, malar rash subsided, pleural effusion and chest symptoms and x-ray showed resolution in 10 days

10 Course Fever persisted high grade every 3 rd day As patient was taking 45 mg prednisolone (good amount!!) SLE fever unlikely Thoroughly evaluated with repeat cultures, Echo, USG abdomen hepatomegaly, Treated empirically with anti-malarial ACT orally Fever daily with increased frequency

11 Course Fundus showing b/l early papillo-edema, no signs of meningeal irritation CSF done normal, MRI brain normal Naprosyn 500 mg bd added, fever responded and subsided completely Likely SLE fever

12 Define Infection fever Clinically infection Culture, serology or clinical diagnosis Response to antibiotic therapy or reduction in Immuno-suppression No flare of lupus Next 4 months

13 Case-2 F/39 Diagnosed SLE 2010 minor organ At present on Azathioprine (2 mg/kg) and prednisolone 7.5 mg Presented with intermittent episodes of fever from oct 2013 Nov 2013 evaluated with admission

14 Nov 2013 No clinical localization for infection or disease activity CT Chest + abdomen normal Echo normal, CSF normal, Bone marrow normal dsdna high in 2010 is 61.2 C3 and C4 90 and 17 mg/dl ESR 20 and CRP 0.7, PCT no report TLC low 3200 Urine no pyuria but culture positive for pseudomonas, blood culture negative?sle fever steroid increased to 12.5 mg

15 Dec 2013 Non-resolving fever Gastroenterology opinion taken for liver biopsy as work-up for PUO But, then planned for a PET-CT Anti dsdna 48.6 IU/ml C3 and C4 100 and 23 mg/dl CRP 5.36 mg/dl, ESR 62 mm at 1 hour TLC low 3500 Steroid dose split to 7.5/5 mg M/E

16 Diagnosis PET-CT revealed abscess in lower pole right kidney Infection leading to fever

17 Define fever d/t both Clinical infection Culture, serology or clinical diagnosis Typical manifestations of SLE activity Response to both antibiotic therapy & increase in Immunosuppression

18 Case-3 M/ f/up SLE in remission off Azoran 1 year and 2.5 mg prdnisolone tapered from 3 months April Presented with fever, abdomen pain and loose stools and urine showing active sediments, complements low, ds DNA >200, PCT 2.10ng/ml, CRP <0.32 mg/dl, ESR 25 Developed Macrophage activation syndrome Treated with pulse steroid and 1 mg/kg prednisolone

19 After 1 month- may 2013 Fever relapse from 2 weeks with pain, swelling and redness in b/l thigh and buttock region MRI showing T2 enhancement of hamstrings, quadriceps and gluteal muscles Treated with vancomycin for 4 weeks and prednisolone reduced to 0.5 mg/kg Local symptoms improved but fever persisted with typical morning rise and decreases after morning steroid dose Steroid dose split fever subsided Complements normal, ds DNA 100, CRP/PCT not done

20 After 1 more month June 2013 Relapse of Fever 2 weeks with abdomen pain and right iliac fossa tenderness CECT abdomen multiple necrotic lymph node Started on ATT By 6 th day he developed multiple pockets of abscess in thigh and buttock region Aspirated pus positive for AFB

21 Define SLE fever No infection identified Diagnosis of Exclusion Follow up is must Features of active SLE Suppressed with hike in steroid No evidence of infection over next 2 weeks Physical examination and Investigations Decision may take a single OPD visit to 2 weeks

22 Suppressed with hike of steroid Two aspects Patient presents with fever and SLE diagnosis is made Follow up SLE patient presents with fever

23 Effect of steroid on fever in lupus Retrospective 22 patients suspected SLE fever 3 developed fatal sepsis at high dose

24 Effective steroid dose for SLE fever 80.6% in 1-5 days

25 Max ineffective steroid dose 5.3% still afebrile, 1 had MAS, 3 had lupus enceph

26 Fever in follow up SLE patients 92 patients (60 renal and 32 non-renal) 13.2+/-8 months f/up Prednisolone 10mg in 82% of flare visits, 3 were receiving NSAIDs Fever is not associated with flare (only 1 patient)

27 Fever in follow up SLE patients 28 patients had significant fever One SLE fever - 20 mg OD 10 mg twice daily 5 had unexplained and resolved 22 had infection as a cause of fever Respiratory tract most commonly involved So, while on follow up and regular treatment, infection is much more likely to cause fever

28 Features of active SLE Normal CRP, Anti ds DNA raised, low complements, normal or low leucocyte count But does not rule out infection particularly in cases where both can co-exist!! So, is there some investigations that can look for infections in flare??

29 Pro-calcitonin

30 Pro-calcitonin (PCT) & lupus PCT levels marker for sepsis Higher (>2 ng/ml) in sepsis & septic shock Correlate with severity of sepsis Response to antibiotics Do not rise significantly in viral infections The Question - cut-off values in localized bacterial & fungal infections?

31 PCT, lupus & Infection Ann Rheum Dis Oct;60(10):988-9.

32 PCT to rule out infection Rule out = PCT of <0.17 ng/ml, NPV = 94% for infection Rule in = 100% specificity PCT>0.5 ng/ml and CRP>13 mg/dl poor sensitivity

33 CRP CRP - not elevated lupus flare Moderate rise - serositis and arthritis Levels are known to rise significantly in infections Considerable overlap But a margin to differentiate between the two

34 CRP to rule out infection CRP cutoff value 1.35 mg/dl 100% sensitive & 90% specific to detect infection

35 ROC of PCT & CRP 34 with infection and 39 with lupus flare

36 Markers of infection & flare

37 Infection and lupus

38 Infection morbidity & mortality

39 Infection & lupus

40 Sites and microorganisms

41 Summary Effective steroid dose can be > 40 mg Follow fever trends after steroid hike Follow up SLE patients infection PCT >2 ng/ml with fall on antibiotic likely infection PCT <0.17 ng/ml unlikely to be infection except viral Higher CRP infection CRP <1.35 mg/dl unlikely to be infection Features of active SLE in absence of evident infection

42 Take home message Infection is the most common cause SLE fever is diagnosis of exclusion Thank you