Critical illness in systemic lupus erythematosus and the antiphospholipid syndrome

Stroke and Multiorgan Failure as the Initial Manifestations of Lupus

Systemic lupus erythematosus (SLE) is a persistent autoimmune disorder that manifests across a spectrum ranging from mild to severe disease, often requiring hospitalization and critical care management. We present a severe case of systemic involvement at its onset. A young woman, with a background of arterial hypertension, presented to the emergency department exhibiting a total anterior circulation stroke and exuberant symmetric lower limb edema. Her condition rapidly deteriorated with neurological impairment, respiratory failure requiring mechanical ventilation, and acute kidney injury prompting her admission to the ICU. Following clinical investigation, a diagnosis of SLE was established, according to the European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) 2019 and Systemic Lupus International Collaborating Clinics (SLICC) 2012 classification criteria. The patient underwent treatment involving high-dose corticosteroids, followed by the Euro-Lupus protocol, resulting in significant improvement, despite her severe neurological deficit at admission. Lupus is a complex disease that is often difficult to diagnose because of its potential to mimic various other conditions. Our report delves into a case of previously undiagnosed lupus leading the patient to the ICU. The clinical scenario described adds valuable insights to the understanding of lupus-related complications and their management through a multidisciplinary approach.

Severe pneumonia in patients with systemic lupus erythematosus admitted to the intensive care unit

BACKGROUND

The aim of this study was to investigate clinical characters and prognosis of patients with systemic lupus erythematosus (SLE) and severe pneumonia admitted to the intensive care unit (ICU).

MATERIALS AND METHODS

We conducted a retrospective study that reviewed all clinical records of patients with SLE and severe pneumonia admitted to the ICU between 2008 and 2020.

RESULTS

A total of 86 SLE patients with severe pneumonia during their first ICU admission were enrolled in this study. Most patients were female (n = 71, 82.5%), and the median age was 42.3 ± 14.7 years. The most common organisms were gram-positive bacteria (20.9%), followed by gram-negative bacteria (18.6%) and fungi (10.4%). A total of 31 patients died within 30 days of ICU admission, and the 30-day mortality was 36%. In binary logistic regression analysis, Acute Physiologic and Chronic Health Evaluation II (APACHE II) score, Sequential Organ Failure Assessment (SOFA) score and mechanical ventilation were dependently associated with 30-day mortality (odds ratio [OR] 2.97, P = 0.016; OR = 4.02, P = 0.023; OR = 1.52, P = 0.036; respectively). Among the other 55 patients, 5 patients died after discharge from the ICU during the long-term follow-up.

CONCLUSIONS

Mortality was high in SLE patients with severe pneumonia admitted to the ICU, and most of the patients died within 30 days of ICU admission.

Continuous renal replacement therapy combined with double filtration plasmapheresis in the treatment of severe lupus complicated by serious bacterial infections in children: A case report

There are few reports available on the combination therapy of continuous renal replacement therapy (CRRT) and double filtration plasmapheresis (DFPP) in patients with systemic lupus erythematosus (SLE) complicated by severe bacterial infections, especially in children. A 14-year-old female child with recurrent SLE complicated by severe sepsis-induced multiple organ dysfunction syndrome was administered CRRT combined with DFPP for blood purification in addition to routine immunosuppressant therapy. The changes in autoantibodies, cytokines, and coagulation function indexes of the patient before and after treatment were compared to explore the effect of such therapy on progression and prognosis. After DFPP therapy, significant decreases in the levels of double-stranded DNA antibody, cytokines interleukin (IL)-6, IL-10, and procalcitonin (PCT) were observed. Fibrinogen (Fib) decreased and needed to be replenished following DFPP. After CRRT combined with DFPP, the patient began to urinate sparingly (urine volume was < 50 mL/day) at the seventh week, the urine volume was > 400 mL/day (up to 560 mL/day) at the ninth week (63 days), and the urine volume was >1,000 mL/day at the tenth week, at which time the renal function had fully recovered. DFPP may reduce the plasma Fib concentration, which needs to be replenished in a timely manner. CRRT combined with DFPP shows efficacy in patients with SLE, but the coagulation function requires close monitoring.

A False-Positive HIV Test: Severe Lupus Flare in Disguise

Systemic lupus erythematosus (SLE) and human immunodeficiency virus (HIV) infection have significant overlapping clinical features, making diagnosis challenging. We report a case of new-onset SLE initially mistreated as HIV infection due to a false-positive fourth-generation HIV antigen/antibody (Ag/Ab) test.

A young female in her 30s presented with fatigue, oral thrush, and a positive HIV Ag/Ab combo test. She was started on fluconazole and highly active antiretroviral therapy (HAART), but deteriorated with recurrent fevers and worsening mental status, requiring ICU admission. Surprisingly, her HIV confirmatory tests were negative, but rheumatologic serologies were positive. The overall clinical, laboratory and biopsy results confirmed the diagnosis of SLE. She was treated with pulse steroid therapy and immunosuppressive agents with marked improvement and was subsequently discharged.

Rarely do SLE patients present with false-positive HIV tests, thus masking and delaying treatment for critical SLE. Clinicians should understand the limitations of screening tests and have high suspicions and consider the diagnoses of both diseases.

Causes of Hospitalization for Systemic Lupus Erythematosus in Saudi Arabia Compared With the Global Setting: A Retrospective Single-center Observational Study

BACKGROUND

This study sought to evaluate the main causes of hospitalization of patients with systemic lupus erythematosus (SLE) in a tertiary health center in Saudi Arabia.

METHODS

A retrospective observational study was performed for all the SLE patients admitted to King Saud Medical City between 2016 and 2019. The primary reason for hospitalization was determined by the primary physician caring for the patient at the time of admission.

RESULTS

Of the 98 hospitalizations for SLE, 49% of patients were admitted from the emergency department (ED) and 51% from the rheumatology clinic. The most common reason for hospitalization was lupus flare (68.4%) followed by infection (20.4%). The lupus flare patients commonly presented with musculoskeletal (MSK)symptoms (34.6%), renal manifestations (25.5%), and skin rash (24.5%), whereas patients admitted with infection were commonly diagnosed with community-acquired pneumonia (12.2%). Other hospitalization causes were obstetric complications, adverse drug reactions, and thrombosis. Intensive care unit (ICU) admission was necessary for 7% of patients due to acute respiratory distress syndrome (ARDS) and pulmonary hemorrhage (28.6%) or other reasons (14.1%), such as pleural effusion, cardiac tamponade, and thrombotic thrombocytopenic purpura (TTP). Conclusions: The two most common reasons for SLE hospitalization were lupus flare and infection. Lupus flare was mainly due to MSK, renal, and dermatologic manifestations. The most common infection leading to hospitalization was community-acquired pneumonia, and ICU admission was mainly due to ARDS and pulmonary hemorrhage.

Development of a Novel Simple Model to Predict Mortality in Patients With Systemic Lupus Erythematosus Admitted to the Intensive Care Unit

Background: Patients with systemic lupus erythematosus (SLE) may sometimes require admission to the intensive care unit (ICU), and the outcome is poor. The aim of this study was to explore the clinical features of patients with SLE in the ICU, identify prognostic factors, and develop and evaluate a prognostic model to predict in-ICU mortality of patients with SLE.

Patients and Methods: This was a single center retrospective study in a tertiary medical institution in China. A total of 480 SLE patients with 505 ICU admissions from 2010 to 2019 were screened, and 391 patients were enrolled. The clinical feature and outcomes of the patients were analyzed. According to the random number table, patients were divided into two mutually exclusively groups named derivation (n = 293) and validation (n = 98). Prognostic factors were identified by a Cox model with Markov Chain Monte Carlo simulation and evaluated by latent analysis. The risk score was developed based on the derivation group and evaluated using the validation group.

Results: Among the 391 patients, 348 (89.0%) patients were females. The median age of patients was 34 years, and the median course of SLE was 6 months. The median APACHE II and SLEDAI were 17 and 10, respectively. The average in-ICU mortality was 53.4% (95% CI, 48.5–58.4%). A total of 186 patients were admitted to the ICU due to infection. Pneumonia (320/391, 81.8%) was the most common clinical manifestation, followed by renal disease (246/391, 62.9%). Nine prognostic factors were identified. The model had C statistic of 0.912 (95% CI, 0.889–0.948) and 0.807 (95% CI 0.703–0.889), with predictive range of 5.2–98.3% and 6.3–94.7% for the derivation and validation groups, respectively. Based on distribution of the risk score, 25.3, 49.5, and 25.2% of patients were stratified into the high, average, and low-risk groups, with corresponding in-ICU mortality of 0.937, 0.593, and 0.118, respectively.

Conclusion: Nine prognostic factors including age, white blood cell count, alanine transaminase, uric acid, intracranial infection, shock, intracranial hemorrhage, respiratory failure, and cyclosporin A/tacrolimus usage were identified. A prognostic model was developed and evaluated to predict in-ICU mortality of patients with SLE. These findings may help clinicians to prognostically stratify patients into different risk groups of in-ICU mortality, and provide patients with intensive and targeted management.

Systemic lupus erythematosus in the intensive care unit: a systematic review

Systemic lupus erythematosus (SLE) is an autoimmune disease with heterogeneous pathophysiologic mechanisms and diverse clinical manifestations. SLE is a frequent cause of intensive care unit (ICU) admissions. Multiple studies with controversial findings on the causes, evolution and outcomes of ICU-admitted patients with SLE have been published. The aim of this paper is to review the literature reporting the clinical characteristics and outcomes, such as mortality and associated factors, in such patients. Among the main causes of ICU admissions are SLE disease activity, respiratory failure, multi-organ failure and infections. The main factors associated with mortality are a high Acute Physiology and Chronic Health Evaluation (APACHE) score, the need for mechanical ventilation, and vasoactive and inotropic agent use. Reported mortality rates are 18.4%-78.5%. Therefore, it is important to evaluate SLE disease severity for optimizing clinical management and patient outcomes.

Epidemiology and outcomes of sepsis among hospitalizations with systemic lupus erythematosus admitted to the ICU: a population-based cohort study

Background

Sepsis is the most common cause of premature death among patients with systemic lupus erythematosus (SLE) aged ≤ 50 years in the United States, and infection is the most common cause of admission to the ICU among SLE patients. However, there are no population-level data on the patterns of the demand for critical care services among hospitalized septic patients with SLE or the outcomes of those admitted to the ICU.

Methods

We performed a retrospective cohort study, using the Texas Inpatient Public Use Data File, to identify SLE hospitalizations aged ≥ 18 years and the subgroups with sepsis and ICU admission during 2009–2014. The patterns of ICU admission among septic hospitalizations were examined. Logistic regression modeling was used to identify predictors of short-term mortality (defined as hospital death or discharge to hospice) among ICU admissions with sepsis and to estimate the risk-adjusted short-term mortality among ICU admissions with and without sepsis.

Results

Among 94,338 SLE hospitalizations, 17,037 (18.1%) had sepsis and 9409 (55.2%) of the latter were admitted to the ICU. Sepsis accounted for 51.5% of the growth in volume of ICU admissions among SLE hospitalizations during the study period. Among ICU admissions with sepsis, 25.3% were aged ≥ 65 years, 88.6% were female, and 64.4% were non-white minorities. The odds of short-term mortality among septic ICU admissions were increased among those lacking health insurance (adjusted odds ratio 1.40 [95% confidence interval 1.07–1.84]), while being unaffected by gender and race/ethnicity, and remaining unchanged over the study period. On adjusted analyses among ICU admissions, the short-term mortality among those with and without sepsis was 13% (95% CI 12.6–13.3) and 2.7% (95% CI 2.6–2.8), respectively. Sepsis was associated with 63.6% of all short-term mortality events.

Conclusions

Sepsis is a major, incremental driver of the demand for critical care services among SLE hospitalizations. Despite its relatively low mortality, sepsis was associated with most of the short-term deaths among ICU patients with SLE.

[Epidemiology and outcome of patients with rheumatic diseases in the intensive care unit]

Patients with rheumatic diseases have an increased risk for admission to an intensive care unit (ICU) compared with individuals without these diseases. Besides cardiovascular events, infection complications are frequently the reason for ICU treatment. For autoimmune systemic diseases, such as systemic lupus erythematosus (SLE) and granulomatosis with polyangiitis (GPA), it is not uncommon for the disease to be first diagnosed during intensive medical care. In addition, flares of these diseases can necessitate ICU admission of the patients. The mortality of patients with rheumatic diseases on the ICU is increased compared with control collectives, especially in patients suffering from life-threatening infections. Treatment with corticosteroids is associated with an increased risk for ICU admission as well as a poorer survival rate. In contrast, patients treated with conventional and biologic disease-modifying anti-rheumatic drugs (DMARD) are less likely to need ICU treatment, compared with rheumatism patients without these medications. Among the established scoring systems applied to estimate the prognosis of ICU patients, the APACHE II score is the best investigated system in patients suffering from rheumatic diseases. This score probably reflects the condition of these patients better than other scoring systems.

Mortality of patients with systemic lupus erythematosus admitted to the intensive care unit - A retrospective single-center study

Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease that results in increased morbidity and mortality. Under certain conditions, patients with SLE may be admitted to the intensive care unit (ICU) secondary to infectious disease flare-ups or other non-SLE disease conditions that are aggravated by SLE. The aim of our study was to investigate the causes and outcomes of ICU-admitted patients with SLE. This is a retrospective cohort study involving paitents with SLE that were admitted to the general ICU at Sheba Medical Center between 2002 and 2015. Outcome was measured by the 30-day mortality and the Acute Physiology and Chronic Health Evaluation (APACHE) II score. Demographic, diagnostic, physiological, and laboratory variables of survivors and nonsurvivors were compared using univariate and multivariate Cox regression analyses. A receiver operating characteristic curve was plotted for significant variables to illustrate their diagnostic capabilities. Twenty-seven patients were admitted to the ICU (female: 21 [77%], mean age ± SD: 51.1 ± 15.4 years). The mean ± SD APACHE II score and 30-day mortality rate were 23.4 ± 8.3 and 29.6%, respectively. Infections, especially lower respiratory tract infections, were the cause of 66.7% of admissions and accounted for 87.5% of deaths. APACHE II scores, bacteremia, and gram-negative infections were significantly associated with mortality (p = 0.033, p = 0.022, and p = 0.01, respectively). An APACHE II score of 27 and above was the strongest predictor of mortality with a sensitivity and specificity of 83.3% and 84.2%, respectively (AUC = 0.82, p = 0.022). Patients with SLE that were admitted to the ICU with gram-negative infections, sepsis, or an APACHE II score of 27 and above have a higher mortality rate and thus should be promptly identified and treated accordingly.

Prognostic factors of mortality in Iranian patients with systemic lupus erythematosus admitted to intensive care unit

The aim was to determine the course, outcome, and determinants of mortality in patients with systemic lupus erythematosus (SLE) in intensive care unit (ICU). SLE patients admitted to ICU from 2004 to 2015 were recruited retrospectively. Demographic data, disease characteristics, causes of admission, baseline SLE disease activity index-2K (SLEDAI-2K) and Acute Physiologic and Chronic Health Evaluation II (APACHE) score, the outcome, and the causes of death were recorded. Predictors of mortality were compared between alive and dead patients by Cox regression analysis. Ninety-four patients with SLE were enrolled. Mean age at the time of ICU admission was 29.6 years. Average scores of SLEDAI and APACHE II were 11.3 and 19.8, respectively. The most common causes of ICU admission were pneumonia, diffuse alveolar hemorrhage (DAH), and seizure. Forty-seven patients (50%) died in ICU. The principal causes of death were septic shock (25.5%), multi-organ failure (12.5%), DAH (10.6%), and pneumonia (10.6%). After multivariate analysis, high APACHE II, septic shock, and duration of mechanical ventilation were indicators of survival outcome. Mean (95% CI) survival days in ICU in patients with and without respiratory failure were 14.6 (10.4-18.9) and 28.7 (17.9-39.5) days, respectively (P = 0.001). This figure for those with and without septic shock was 13.5 (4.9-11.1) and 22.3 (9.3-24.7) days, respectively (P = 0.016). High APACHE II, septic shock, and duration of mechanical ventilation were the main predictors of death in patients with SLE in ICU. Multicenter studies are needed to draw a fine picture of SLE behavior in ICU.

Outcome of patients with systemic lupus erythematosus in intensive care unit

The objective of the study was to identify the causes, outcome and prognosis of severe illness in patients with systemic lupus erythematosus (SLE) requiring intensive care unit (ICU) care in a University Hospital over a five-year period. The design was a cohort study. Forty-eight SLE patients requiring ICU management over a five-year period (January 1997-December 2001) were studied prospectively. Of 48 patients, 14 (29.2%) died, predominantly with multiorgan dysfunction syndrome (MODS). Patients whose APACHE II score was equal to or greater than 20 had higher mortality than those with APACHE score below 20 (60 versus 7.1%; and P, 0.01). All the 18 patients whose health status rated as ‘good’ survived, while 46.7% of 30 patients whose health rated as ‘poor’ died (P, 0.01). Patients who had thrombocytopenia associated with sepsis and/or disseminated intravascular coagulopathy (DIC) had the highest mortality (75%, five-year survival). In conclusion, SLE patients admitted to the ICU had a lower mortality rate than some of the previous reports. Patients with SLE with high APACHE score, ≥20, poor health status, thrombocytopenia and multiorgan dysfunction syndrome had poor prognosis in the ICU.

Outcomes in critically ill patients with systemic rheumatic disease: a multicenter study

BACKGROUND

Patients with systemic rheumatic diseases (SRDs) may require ICU management for SRD exacerbation or treatment-related infections or toxicities.

METHODS

This was an observational study at 10 university-affiliated ICUs in France. Consecutive patients with SRDs were included. Determinants of ICU mortality were identified through multivariable logistic analysis.

RESULTS

Three hundred sixty-three patients (65.3% women; median age, 59 years [interquartile range, 42-70 years]) accounted for 381 admissions. Connective tissue disease (primarily systemic lupus erythematosus) accounted for 66.1% of SRDs and systemic vasculitides for 26.2% (chiefly antineutrophil cytoplasm antibodies-associated vasculitides). SRDs were newly diagnosed in 43 cases (11.3%). Direct admission to the ICU occurred in 143 cases (37.9%). Reasons for ICU admissions were infection (39.9%), SRD exacerbation (34.4%), toxicity (5.8%), or miscellaneous (19.9%). Respiratory involvement was the leading cause of admission (56.8%), followed by shock (41.5%) and acute kidney injury (42.2%). Median Sequential Organ Failure Assessment (SOFA) score on day 1 was 5 (3-8). Mechanical ventilation was required in 57% of cases, vasopressors in 33.9%, and renal replacement therapy in 28.1%. ICU mortality rate was 21.0% (80 deaths). Factors associated with ICU mortality were shock (OR, 3.77; 95% CI, 1.93-7.36), SOFA score at day 1 (OR, 1.19; 95% CI, 1.10-1.30), and direct admission (OR, 0.52; 95% CI, 0.28-0.97). Neither comorbidities nor SRD characteristics were associated with survival.

CONCLUSIONS

In patients with SRDs, critical care management is mostly needed only in patients with a previously known SRD; however, diagnosis can be made in the ICU for 12% of patients. Infection and SRD exacerbation account for more than two-thirds of these situations, both targeting chiefly the lungs. Direct admission to the ICU may improve outcomes.

Antiphospholipid antibodies in critically ill patients

Antiphospholipid antibodies are responsible for a wide spectrum of clinical manifestations. Venous, arterial and microvascular thrombosis and severe catastrophic cases account for a large morbidly/mortality. Through the connection between the immune, inflammatory and hemostatic systems, it is possible that these antibodies may contribute to the development of organ dysfunction and are associated with poor short and long-term prognoses in critically ill patients. We performed a search of the PubMed/MedLine database for articles written during the period from January 2000 to February 2013 to evaluate the frequency of antiphospholipid antibodies in critically ill patients and their impact on the outcomes of these patients. Only eight original studies involving critically ill patients were found. However, the development of antiphospholipid antibodies in critically ill patients seems to be frequent, but more studies are necessary to clarify their pathogenic role and implications for clinical practice.

Outcomes and Prognostic Factors in Patients with Rheumatologic Diseases Admitted to the ICU

OBJECTIVE

To assess the outcomes in a large cohort of patients suffering from rheumatic diseases admitted to the ICU of a tertiary university medical center.

METHODS

A retrospective chart analysis was performed in 108 patients suffering from various rheumatic diseases and the outcomes, including morbidity and mortality, were assessed in relation to the underlying diseases, treatments and complications.

RESULTS

Overall, 48 patients with rheumatoid arthritis, five patients with spondyloarthritis, 14 patients with vasculitis, 30 patients with connective tissue diseases and 11 patients suffering from other rheumatologic conditions were admitted to the intensive care unit (ICU). The reasons for ICU admission included infection (30%), cardiovascular complications (22%), gastrointestinal problems (18%), endocrinological disorders (7%), neurological complications (2%) and others (3%). A total of 4% of the admitted patients required close monitoring and 14% suffered from acute exacerbation of the underlying rheumatic disease. The ICU mortality rate was 16%, whereas the overall hospital mortality rate was 20%. Fatal outcomes were related to exacerbation of the rheumatic disease in 14% of the patients, infectious complications in 46% of the patients and other reasons in 41% of the patients. An increased Apache II score, the need for mechanical ventilation, renal replacement therapy, treatment with vasopressor drugs and plasma exchange therapy were identified as risk factors for mortality.

CONCLUSION

The overall outcomes of critically ill patients with rheumatic diseases are impaired compared to that observed in other patient groups. However, there were no significant differences in outcomes between the different rheumatic disease groups or based on the use of immunosuppressive therapy in this study. An increased Apache II score, the need for mechanical ventilation, renal replacement therapy, treatment with vasopressor drugs and plasma exchange therapy were identified as risk factors for mortality.

Efficacy and safety of nonbiologic immunosuppressants in the treatment of nonrenal systemic lupus erythematosus: a systematic review

OBJECTIVE

To analyze the efficacy and safety of nonbiologic immunosuppressants in the treatment of nonrenal systemic lupus erythematosus (SLE).

METHODS

We conducted a sensitive literature search in Medline, Embase, and the Cochrane Central Register of Controlled Trials up to October 2011. The selection criteria were studies including adult patients with SLE, a treatment intervention with nonbiologic immunosuppressants, a placebo or active comparator group, and outcome measures assessing efficacy and/or safety. Meta-analyses, systematic reviews, clinical trials, and cohort studies were included. The quality of each study was evaluated using Jadad’s scale and the Oxford Levels of Evidence.

RESULTS

In total, 158 of the 2,827 initially found articles were selected for detailed review; 65 studies fulfilled the predetermined criteria. Overall, the studies were low quality, with only 11 randomized controlled trials (RCTs). Cyclophosphamide demonstrated efficacy for neuropsychiatric SLE, preventing relapses with an additional steroid sparing effect, although its use was associated with cumulative damage, development of cervical intraepithelial neoplasia,and ovarian failure. Other immunosuppressants (azathioprine, methotrexate, leflunomide, mycophenolate mofetil,and cyclosporin A) demonstrated efficacy in reducing nonrenal activity and flares with a steroid-sparing effect, although only on occasion in non–placebo-controlled RCTs of small numbers of patients.

CONCLUSION

Several immunosuppressants demonstrated their safety and efficacy in nonrenal SLE. A specific drug for each particular manifestation cannot be recommended, although cyclophosphamide may be used in more severe cases, and methotrexate may be the first option in most cases of moderately active SLE. High-quality RCTs of larger numbers of patients are needed.

Clinical presentations and outcomes of systemic lupus erythematosus patients with infection admitted to the intensive care unit

Objective

The objective of this article is to investigate clinical presentations and outcomes of systemic lupus erythematosus (SLE) patients with infection admitted to the intensive care unit (ICU).

Methods

SLE patients with infection, SLE patients with noninfectious causes, and non-SLE patients with infection were identified from the Cooper University Hospital Project IMPACT database between 2002 and 2010. We examined demographic data, APACHE II scores, physiologic data, laboratory data, length of stay in the ICU and hospital, and mortality of the three groups.

Results

Twenty-five SLE patients with infection, 45 SLE patients with noninfectious causes, and 1466 non-SLE patients with infection were included in the study. SLE patients with infection had higher APACHE II scores, higher maximum temperature, higher minimum and maximum heart rate (HR), lower minimum and maximum systolic blood pressure (SBP), and longer ICU length of stay in comparison to SLE patients with noninfectious causes. There were no statistical differences in white blood cell (WBC) count. SLE patients with infection had a higher mortality compared to SLE patients with noninfectious causes. There was no difference in mortality between SLE patients with infection and non-SLE patients with infection.

Conclusion

SLE patients with infection in the ICU had a higher mortality and a higher APACHE II score compared to SLE patients with noninfectious causes in the ICU. Their physiologic signs including temperature, HR, and SBP were more reflective of infection than their WBC count.

Prognostic contributions of the underlying inflammatory disease and acute organ dysfunction in critically ill patients with systemic rheumatic diseases

BACKGROUND

Knowledge about the clinical features, outcomes and predictors of short-term mortality in critically ill patients with systemic rheumatic disease (SRD) requires further characterization.

METHODS

Single center retrospective observational cohort study of 149 critically ill patients with SRD followed in a French medical intensive care unit over a 20-year period. Multivariate logistic regression was used to identify predictors of day-30 mortality.

RESULTS

Most patients (63%) had systemic lupus erythematosus, rheumatoid arthritis, or systemic sclerosis. The critical illness usually developed late after the diagnosis of SRD (median time to ICU admission 82 months, IQR [9-175] in the 127 patients with a previous diagnosis of SRD). Two-thirds of patients were taking immunosuppressive drugs to treat their SRD. Reasons for ICU admission were infection (47%), SRD exacerbation (48%), and iatrogenic complications (11%); the most common organ failure was acute renal failure. Thirty-day mortality was 16%. Predictors of 30-day mortality were the LODS score on day 1 (OR 1.3 (1.06-1.48)), bacterial pneumonia (OR 3.8 (1.03-14.25)), need for vasoactive drugs (OR 7.1 (1.83-27.68)), SRD exacerbation (OR 4.3 (1.15-16.53)), and dermatomyositis (OR 9.2 (1.05-80.78)) as the underlying disease. Year of ICU admission was not significantly associated with 30-day survival.

CONCLUSION

Patients with SRD are mostly admitted in the ICU with infection or SRD exacerbation, and can be treated with immunosuppressive therapy and life-sustaining interventions with acceptable 30-day mortality. Death is associated with both the severity of the acute medical condition and the characteristics of the underlying SRD.

Temporal trends in characteristics and outcome of intensive care unit patients with systemic lupus erythematosus in Taiwan: a national population-based study

This study assessed temporal trends in characteristics and outcome of the intensive care unit (ICU) patients with systemic lupus erythematosus (SLE). We analyzed 2870 SLE patients (≥15 years) with first-time ICU admission between 1999 and 2008. Patient data were retrieved from the Taiwan National Health Insurance Research Database. Median age of the patients increased from 38.5 to 44.0 years during the study period. Most patients were women (overall 85.5%); the proportion varied insignificantly over time. Median duration from SLE diagnosis to ICU admission (disease duration) increased by four years. The proportion of patients with disease duration of more than three years increased from 42.6% to 61.4%, whereas the proportion of patients with a primary rheumatic diagnosis decreased from 41.7% to 25.1%. The incidence of infection increased from 39.1% to 47.2%. The incidence of organ dysfunction increased from 64.1% to 69.2%, especially in neurological, cardiovascular, and respiratory systems. Conversely, the incidence of renal dysfunction decreased from 36.2% to 28.8%. Meanwhile, there were decreasing uses of hemodialysis (from 37.3% to 28.7%) and vasopressors (from 58.3% to 47.9%). Hospital mortality also decreased from 42.6% to 31.2% during the 10 years. After the patient and hospital characteristics were adjusted, patients admitted in 2007 and 2008 were 50% less likely to die than those admitted in 1999 and 2000 (adjusted odds ratio 0.5, 95% confidence interval 0.38-0.67). This study demonstrates a temporal improvement of the short-term survival of the ICU patients with SLE in Taiwan despite changing characteristics and increasing severity of the acute critical illnesses.

[Rheumatic patients in the intensive care unit]

The mortality of patients with rheumatic diseases in the intensive care unit is generally high despite their relatively young age. In these patients, it is often difficult to make the diagnosis of the underlying autoimmune disease or to differentiate between septic complications and an acute flare; likewise, the complexity of the specific antirheumatic therapy can also be accompanied by problems. The following article gives an overview of problems in the diagnosis and treatment of critically ill patients with autoimmune diseases in the intensive care unit.

Influence of antiphospholipid antibody levels and type on thrombotic manifestations: results from the Serbian National Cohort Study

Repeated thromboses are the most frequent clinical manifestation of antiphospholipid syndrome (APS) in the presence of antiphospholipid antibodies (aPL). The objective of this study was to observe the prevalence and localization of thrombosis, and to investigate the importance of aPL type and level for thrombosis-related events in patients diagnosed with APS. These are the first results of patients enrolled in Serbian National Cohort Study which comprises 256 patients: 162 with primary antiphospholipid syndrome (PAPS) and 94 with APS associated with systemic lupus erythematosus (SLE). aPL analysis included detection of aCL (IgG/IgM), β(2)GPI, and lupus anticoagulant. Thrombosis was diagnosed in 119 (46.5%) patients, with higher prevalence in PAPS compared with SLE patients (51.2% and 38.3%, respectively, p = 0.045). There was similar prevalence of arterial thrombosis in PAPS and SLE groups (34.6% and 34%, respectively, p = 0.932) although venous thrombosis was more frequent in PAPS (25.9% and 8.5%, respectively, p = 0.001). Thrombosis was observed in 92 (55.8%) patients who had more than one type of antibody (category I), in 13 (41.9%) patients with category IIa, in 19 (46.3%) patients with category IIb, and in 73 (44.2%) patients with category IIc (p = 0.10). The patients with thrombosis were older than those without thrombosis (49.8 and 39.8 years, respectively, p = 0.001). Overall, older age was a risk factor for thrombosis. The prevalence of venous thrombosis was higher in the PAPS group, but with lower frequency than in literature data. Any aPL type and level is a risk factor for thrombosis.

Outcome of patients with connective tissue disease requiring intensive care for respiratory failure

Occasionally acute respiratory failure (ARF) develops in patients with connective tissue disease (CTD), but the etiologies of ARF in these patients are not fully elucidated. The objective of this study is to find out the causes of ARF leading to intensive care unit (ICU) admission in these patients and to assess their clinical outcome. The medical records of 1,870 consecutive patients admitted to the ICU in Seoul National University Hospital since January 2005-September 2008 were reviewed. A total of 66 patients with CTD were analyzed. The median age was 58 years, and 45 patients were women. The median length of ICU stay was 16 days with a median duration of mechanical ventilation support of 15 days. The distribution of underlying CTD was 17 patients with systemic lupus erythematosus; 15 with rheumatoid arthritis; 14 with systemic vasculitis; and nine with polymyositis-dermatomyositis. Pneumonia was the leading cause of ARF in 24 patients (36%). We could not identify the cause of ARF in 14. Other causes of ARF were acute pulmonary edema for nine patients, diffuse alveolar hemorrhage for eight and Pneumocystis pneumonia for four. Forty-one patients (62%) died during admission, and the mortality rate was the lowest in those with acute pulmonary edema. Use of norepinephrine was statistically higher in nonsurvivors. We could identify the cause of ARF leading to ICU admission in at least 80% of patients with CTD. However, these patients still showed a high mortality rate regardless of etiology. Their survival might be influenced by hemodynamic status.

Fatal infection in children with lupus nephritis treated with intravenous cyclophosphamide

A knowledge of the causes and risk factors of fatal infection in childhood lupus nephritis (LN) patients treated with intravenous cyclophosphamide (IVCY) is important to enable optimal treatment. During an 11-year period (1996-2007), severe infection cases occurred in 31/84 (36.9%) patients with 64 infection episodes in our central referral institution in southern Thailand. Fatal infections occurred in 13/31 (41.9%) patients, most (11/13, 84.6%) during the first infective episode. The major causative organisms of the fatal infections were fungus and Gram-negative bacilli. Fatal infections were more likely to occur in patients with a prior history of treatment with pulse methylprednisolone and in patients with more active LN, as evidenced by the higher proteinuria and serum creatinine levels and lower hemoglobin and lymphocyte counts in this group than in patients with non-fatal infections. Multivariate analysis indicated that factors associated with fatal infection were prior treatment with pulse methylprednisolone [odds ratio (OR) 11.2, 95% confidence interval (CI) 1.9-61.0], renal failure (OR 5.9, 95% CI 1.0-34.8), and fungal infection (OR 23.9, 95% CI 1.9-298.2). Cases of active LN treated with IVCY and pulse methylprednisolone who later develop severe infection that fails to respond to antibiotics should be carefully investigated for fungal infection.

Hughes syndrome (the antiphospholipid syndrome): 25 years old

The antiphospholipid (Hughes) syndrome (APS) is a unique thrombotic disorder, causing both arterial and venous thrombosis, linked to the presence of antibodies directed against phospholipid-protein complexes. The first papers describing the syndrome were published in 1983 and, over the next two years, a series of publications described in detail the various clinical manifestations of the syndrome. Laboratory standardisation workshops were also set up and, in 1984, the first "world" symposium on APS was held. The international APS conferences have continued to grow in numbers and in stature. The APS has already had an impact in obstetrics, in medicine, in psychiatry, and in surgery. The approximate figure of 1 in 5 is a useful guide -- 1 in 5 of all young strokes, 1 in 5 recurrent miscarriages, 1 in 5 DVTs. More precise data will become available in the worlds of epilepsy, migraine, Alzheimer's, and MS. The advent of newer "biologic" immunosuppressives such as rituximab may offer help in selected cases. Intravenous immunoglobulin has proved successful, especially in the emergency setting.

Intravenous immunoglobulin therapy of lupus pneumonitis

Acute lupus pneumonitis in an 11-year-old girl with lupus nephritis is reported. Chest radiograph and arterial blood gas parameters were suggestive of Acute Respiratory Distress Syndrome (ARDS). Definitive pulmonary infection was excluded by investigations and poor clinical response to antibiotics. The respiratory worsening warranted ventilatory support with very high pressures. A trial of intravenous immunoglobulin was given following which there was improvement in the ventilatory requirements by 36 hours. The child was successfully weaned off ventilator and discharged from ICU by day 7. The role of intravenous immunoglobulin during acute life threatening pulmonary emergencies in a case of SLE prompted this clinical brief.

Survival of patients with SLE admitted to an intensive care unit—a retrospective study

We examined the demography, reasons for admission and cause of death in systemic lupus erythematosus (SLE) patients admitted to a medical intensive care unit (ICU) over a 7-year period. Fourteen patients were admitted during this period-all were female, 13 were of mixed ethnic ancestry and one a black South African. Of the 14 patients, 12 were admitted as a result of lupus activity, 2 had sepsis as the major cause of admission, although 5 other patients developed infection during their admission. Five patients had a generalised flare of their disease or progressive renal failure. Seven patients were admitted with a variety of lupus-related pathologies. In general the precise cause of death was difficult to determine. Of the 14 patients, 9 had impaired renal function on admission including 1 with sepsis and 1 of the survivors. Three patients (21%) survived, one with respiratory failure due to shrinking lung, a second with an acute flare of SLE and a third with pulmonary emboli. This study demonstrates that lupus in our community may produce life-threatening flares. Although cause of death was not always definitely identified, admission to the ICU was primarily due to active SLE and not sepsis or iatrogenic disease.