Rachmat Gunadi Wachjudi is a doctor born in Garut, Indonesia in 1955. He received his medical degree from FK UNSRI Palembang and completed internships and specializations in internal medicine and rheumatology. He currently works in the Rheumatology Division at Rumah Sakit dr Hasan Sadikin Bandung. He is a member of several medical organizations related to internal medicine and rheumatology.
NEUROLOGICAL MANIFESTATIONS OF HIV/AIDS: A CLINICAL PROSPECTIVE STUDYEarthjournal Publisher
&Objectives: To study the clinical profile of neurological manifestations of Human immunodeficiency
virus(HIV)/Acquired immunodeficiency syndrome(AIDS) and to correlate with the CD4+T lymphocyte
count.Material & Methods : 50 patients who were in the age goup18-55 years, had HIV infection and history
suggestive of Nervous system manifestations were included. The HIV patients with past/present history of
other immunocompromised conditions ( cytotoxic drugs for malignancies, Post organ transplant patients,
Patients using steroids for long term), previous history of epilepsy, focal neurological deficit and head injury
were excluded from the study. All the patients were examined in detail by history and clinical neurological
examination. For all the patients have done routine investigations, and specific investigations like CT/MRI
Brain, Nerve Conduction Studies, CSF Analysis,EEG and Specific antibodies for organisms or parasite done
only wherever it is required. All the patients were correlated with the CD4 T cell count.Results:: Among 50
patients, Commonest age group affected was 26-35 yrs with male predominance(62%). Most common symptom
was non specific headache(38%).Most common opportunistic infetction was Tuberculous meningitis(34%).
Toxoplasmsa encephalitis was the most common space occupying lesion(20%).More number of patients were
seen in the CD4 range in between 51-200 cells/mic.L(72%) with all the diseases had correlation with CD4 T cell
activityCONCLUSION: In the present study, Opportunistic infections were the leading cause in patients
infected with HIV having Neurological manifestastions, usually occurs when the patients had severe
immunosuppresion (CD4 count< 200 cells/μL).
Key words: HIV Positive patients, CD4 T cell count, Neurological manifestation
Theodoros Katsivas, MD (UC San Diego Owen Clinic), Shira Abeles, MD (UC San Diego Owen Clinic) and Robyn Cunard, MD (UC San Diego) present "Renal Disease in HIV/AIDS"
Clinical and Laboratory Prognostic Factors in Malignant form of Mediterranean...inventionjournals
Mediterranean spotted fever (MSF) caused by Rickettsia conorii has become a significant health risk for suffering people and international travelers. In the past, overlooked as a serious disease, at present it is known that MSF was wrongly considered a benign condition. In this report, we present a set of clinical features and laboratory parameters in 55 patients (19 fatalities and 36 survivors) with malignant forms of the disease. The purpose of the study was to outline the prognostic factors of the fatal outcome in patients with malignant MSF. Based on our data, the main prediction factors for mortality in malignant MSF patients were: advanced age, delayed hospital admission, severe concomitant diseases, and failure to start or to complete appropriate antibiotic treatment. Laboratory prognostic factors in fatalities were: leukocytosis with a marked shift to the left; extremely high serum urea and creatinine levels; low levels of fibrinogen and prolongation of thrombin time. The most frequently involved organ systems of malignant cases were: central nervous system 100%, liver 92.72%, kidneys 60%, lungs 58.18%, myocardium 30.9%, and gastrointestinal tract 23.63%. The conducted histopathological investigations revealed lethal complications: encephalitis, brain edema, acute respiratory distress syndrome, non-cardiogenic lung swelling, acute myocarditis, gastrointestinal bleeding, hemorrhagicnecrotizing pancreatitis and acute renal failure
Approach to Aquatic Skin & Soft Tissue Infections. Clinical Microbiology Residency Program
King Fahd Hospital of The University, Al Khobar
Saudi Arabia
NEUROLOGICAL MANIFESTATIONS OF HIV/AIDS: A CLINICAL PROSPECTIVE STUDYEarthjournal Publisher
&Objectives: To study the clinical profile of neurological manifestations of Human immunodeficiency
virus(HIV)/Acquired immunodeficiency syndrome(AIDS) and to correlate with the CD4+T lymphocyte
count.Material & Methods : 50 patients who were in the age goup18-55 years, had HIV infection and history
suggestive of Nervous system manifestations were included. The HIV patients with past/present history of
other immunocompromised conditions ( cytotoxic drugs for malignancies, Post organ transplant patients,
Patients using steroids for long term), previous history of epilepsy, focal neurological deficit and head injury
were excluded from the study. All the patients were examined in detail by history and clinical neurological
examination. For all the patients have done routine investigations, and specific investigations like CT/MRI
Brain, Nerve Conduction Studies, CSF Analysis,EEG and Specific antibodies for organisms or parasite done
only wherever it is required. All the patients were correlated with the CD4 T cell count.Results:: Among 50
patients, Commonest age group affected was 26-35 yrs with male predominance(62%). Most common symptom
was non specific headache(38%).Most common opportunistic infetction was Tuberculous meningitis(34%).
Toxoplasmsa encephalitis was the most common space occupying lesion(20%).More number of patients were
seen in the CD4 range in between 51-200 cells/mic.L(72%) with all the diseases had correlation with CD4 T cell
activityCONCLUSION: In the present study, Opportunistic infections were the leading cause in patients
infected with HIV having Neurological manifestastions, usually occurs when the patients had severe
immunosuppresion (CD4 count< 200 cells/μL).
Key words: HIV Positive patients, CD4 T cell count, Neurological manifestation
Theodoros Katsivas, MD (UC San Diego Owen Clinic), Shira Abeles, MD (UC San Diego Owen Clinic) and Robyn Cunard, MD (UC San Diego) present "Renal Disease in HIV/AIDS"
Clinical and Laboratory Prognostic Factors in Malignant form of Mediterranean...inventionjournals
Mediterranean spotted fever (MSF) caused by Rickettsia conorii has become a significant health risk for suffering people and international travelers. In the past, overlooked as a serious disease, at present it is known that MSF was wrongly considered a benign condition. In this report, we present a set of clinical features and laboratory parameters in 55 patients (19 fatalities and 36 survivors) with malignant forms of the disease. The purpose of the study was to outline the prognostic factors of the fatal outcome in patients with malignant MSF. Based on our data, the main prediction factors for mortality in malignant MSF patients were: advanced age, delayed hospital admission, severe concomitant diseases, and failure to start or to complete appropriate antibiotic treatment. Laboratory prognostic factors in fatalities were: leukocytosis with a marked shift to the left; extremely high serum urea and creatinine levels; low levels of fibrinogen and prolongation of thrombin time. The most frequently involved organ systems of malignant cases were: central nervous system 100%, liver 92.72%, kidneys 60%, lungs 58.18%, myocardium 30.9%, and gastrointestinal tract 23.63%. The conducted histopathological investigations revealed lethal complications: encephalitis, brain edema, acute respiratory distress syndrome, non-cardiogenic lung swelling, acute myocarditis, gastrointestinal bleeding, hemorrhagicnecrotizing pancreatitis and acute renal failure
Approach to Aquatic Skin & Soft Tissue Infections. Clinical Microbiology Residency Program
King Fahd Hospital of The University, Al Khobar
Saudi Arabia
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
Secondary Immunodeficiency
By Dr. Usama Ragab Youssif
Reference: Included in Slides
Include causes of secondary immunodeficiency including AIDS and other viral infections
Pearls about NSAIDs and their usage in the managaement of chronic pain, considering safety profile of both selective cox-2 or non selective cox-2 inhibitors
A comprehensive talk about rheumatic autoimmune diseases for patients and family or people interested in understanding SLE, Systremic sclerosis, dermatomyositis, rheumatoid arthritis. Some slides in Bahasa Indonesia.
A systematic approach as to how general physician assessing a patient with musculoskeletal pain with confident; with rheumatoid arthritis as a model. prepared with help of Dr. Perdana Aditya SpPD.KR from UNIBRAW Malang
A brief review about the role of vitamin D in health and disease. Most of the content in these slides were taken from another author with some editing to custom it for the purpose of general physician workshop scientific material. Some figures were our own data in our hospital
This is a brief introduction regarding selected rheumatic autoimmune disease for laymen. Some of these figures in the slides were cited from textbook and another authors elesewhere, and some of them were photos of patient taken with their permission
Penyakit Autoimun penting dikenali masyarakat awam karena gejalanya yang tersamar antar sesama autoimun, bahkan dengan penyakit lain yang bukan autoimun.
Sebuah edukasi pasien tentang lupus, meliputi berbagai aspek yang patut diketahui, agar pasien dan keluarganya tidak larut dalam fase denial dan bargaining yang berkepanjangan
Komordibitas pada pasien dengan gout di poliklinik reumatologi (edit)Rachmat Gunadi Wachjudi
Bagaimana komorbiditas pasien Gout di Indonesia ? Ini merupakan penelitian di satu rumah sakit di Bandung mengenai komorbiditas para penderita pirai alias gout
Beberapa kondisi klini yang harus membuat para praktisi klinis mulai mencurigai adanya penyakit autoimmune. Dijelaskan dengan beberapa contoh autoimmune dseases
Pengenalan artritis reumatoid berdasarkan gejala dan tanda klinis
Bisa dipakai sebagai rujukan bagi dokter umum yangh ingin mempelajari manifestasi klinis AR yang tidak klasik seperti di buku teks
an overview of Lupus for journalist
Lupus has a wide spectrum of manifestation. Some mild but in most cases it has a high impact of life and quality of life
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Preventing infections in patients with autoimmune diseases gunadi
1. Rachmat Gunadi Wachjudi
Lahir di Garut 16 Januari 1955
Pendidikan
- Dokter umum FK UNSRI Palembang
-Internist FK UNPAD Bandung
-Subspesialis Reumatologi FK UI Jakarta
- Clinical Rheumatology and Osteoporosis
Training – Perth - WA
Pekerjaan
Ka Div Reumatologi
Departemen Ilmu Penyakit Dalam
Rumah Sakit dr Hasan Sadikin Bandung
Organisasi:
IDI, PAPDI, IRA, PEROSI, PERALMUNI
1
5. Pick an organ, any organ . . .
Autoimmunity can affect ANY organ/organ system in the human body
Autoimmune Uveitis Multiple Sclerosis
Sjogren’s Syndrome
Psoriasis
Systemic Lupus Erthematosus
Rheumatic Fever
Diabetes
Autoimmune Hepatitis
Addison’s Disease
Autoimmune Oophoritis Ulcerative Colitis
Rheumatoid Arthritis
Autoimmune hemolytic Anemia
5
16. Current Therapies
• Immunosuppressive drugs
- corticosteroids, azathioprine
- slows the proliferation of lymphocytes
Cyclosporin A
• Biologic agents
• Thymectomy
• IvIg
• Plasmapheresis
16
17. Infections
• Are one of the most common causes of
– morbidity,
– hospitalization
– death
in patients with systemic lupus
erythematosus
17
18. Infection in SLE
• is complex, different populations
• Hospitalized and ambulatory cohorts
• Regional differences in pathogens.
• Opportunistic infections in SLE, may be underreported
• Guidelines for antimicrobial prophylaxis exist for persons with
HIV or patients undergoing hematopoietic stem-cell transplant
and have decreased incidence of death and hospitalization due
to opportunistic infections such as pneumocystis.
• Guidelines for Infection Prevention in SLE ?
18
19. Systematic strategy
• In the absence of definitive studies on the use of infection
prophylaxis in SLE, we propose a systematic strategy for
preventing opportunistic infections in SLE patients
starting with their first clinical evaluation
19
20. Infections
• A major cause of mortality in systemic lupus erythematosus
• In a large multicentre European cohort of 1000 patients followed
over 10 years, infections represented the cause of death in 25%
of cases and active SLE in 26.5%.
• Bimodal distribution to death in SLE
– Infections and active disease causing death within the first 5
years of diagnosis,
– myocardial infarctions and thrombotic events occurring later
• Infections are also responsible for 14–50% of hospitalizations in
patients with SLE[and are a cause of significant morbidity. (46%
RSHS)
20
21. Risk factors for infection in systemic
lupus erythematosus
• Disease-associated risk factors
• Disease activity or organ damage
• Medications
• Laboratory findings
• Other risk factors
21
22. Immune defects seen in patients with systemic
lupus erythematosus and potential pathogens
• Hypocomplementemia : Neisseria species, Streptococcus
pneumoniae
• Hyposplenism: Streptococcus pneumonial , Haemophilus
influenzae , Neisseria meningitidis, Salmonella species
• Impaired phagocytic cell activity: Bacterial and fungal
infections (variety of potential organisms)
• Impaired T-cell activity: Herpes simplex and herpes zoster,
Epstein Barr virus and CMVHuman papillomavirus, Influenza,
Listeria monocytogenes , Nocardia species , Cryptococcus
neoformans , Mycobacterium tuberculosis , Nontuberculous
mycobacteria, Pneumocystis jirovici , Histoplasma capsulatum,
Coccidiodes immitis, Toxoplasma gondii
22
24. Other immunosuppressive agents:
• Azathioprine, cyclophosphamide, mycophenolate mofetil
Lead to decline in numbers of B and T cells
– Bacteria (Salmonella species, Listeria monocytogenes,
Nocardia species)
– Viruses (herpes simplex virus, varicella zoster virus)
– Fungi (Pneumocsystis jiroveci,Candida species, endemic
mycoses)
– Parasites: Strongyloides stercoralis
24
25. Bacterial Infections
• The majority of reported infectious complications in patients with
SLE are bacterial
• The most frequent types of infections are respiratory, urinary
tract and soft tissue infections.
• Case series also suggest an increased risk of nontyphoid
salmonella infection.
• Prompt treatment of any identified or suspected infection is
recommended.
• Patients with SLE in which a delay in antimicrobial therapy (> 24
h) a higher risk of mortality
25
26. Vaccination
• Pneumococcal Vacc considered well tolerated recommended
for patients with SLE.
• Although disseminated Neisserial infections have been reported
in patients with SLE and some authors advocate for
meningococcal vaccination, no guidelines exist to date and there
is little research in this area.
26
27. Varicella Zoster Virus
• Most commonly reported viral infections in SLE, from
reactivation of latent varicella zoster virus.
• Disseminated disease in patients with SLE or may be
complicated by superinfection and postherpetic neuralgia.
• Annual incidence of 6.4 events/1000 patient years. (38 HZ case
in 69 SLE pts /5 yr)
• Herpes zoster is a late complication: 5 years after SLE diagnosis
• Commonly during periods of inactive or mild SLE disease
activity.
• Risk factors for herpes zoster include renal disease, concurrent
or prior malignancy and azathioprine and cyclophosphamide use
27
28. H zoster vaccination
• Centre for Disease Control Advisory Committee on Immunization
Practices recommends vaccination in
• patients over age 60, 2–4 weeks prior to any anticipated
immunosuppression, including high dose prednisone (≥20
mg/day lasting ≥2 weeks).
• At least 1 month after discontinuation of such therapy:
• Low doses of methotrexate (≤0.4 mg/kg/week) or azathioprine
(≤3.0 mg/kg/day) is not contraindicative to the administration of
zoster vaccine.
28
29. Human Papillomavirus
• A common viral infection in patients with SLE.
• HPV types 16 and 18 are associated with squamous
intraepithelial lesions (SIL) and cervical cancer.
• High numbers of patients with SLE have HPV infection and SIL
and women with SLE have a three-fold increase in the rate of
abnormal cervical cytology smears compared with the general
population.
• There are currently no recommendations or data regarding the
use of this vaccine in patients with SLE, but it should be offered
to patients meeting recommendations for the general population.
•
29
30. Cytomegalovirus
• Is common in the general population with seropositivity
estimated at 60–70%.
• Over 90% of SLE patients are seropositive for CMV,
antigenemia is detected in 18–44% of patients, whereas overt
clinical disease is rare but carries a high risk of mortality.
• Given the potential for morbidity in immunosuppressed patients
with SLE who develop end-organ disease, we recommend
vigilance on the part of the clinician in considering CMV as a
possible cause of unexplained cytopenias, persistent fevers,
colitis or retinitis in patients receiving immunosuppressive
medications for the treatment of SLE.
•
30
31. Influenza
• The annual incidence of influenza in the general population is 5–
20%; however, the rate of infection in SLE patients is not well
defined.
• The influenza vaccine is the most effective way to prevent
infection and reduce morbidity and mortality; however, it is
slightly less immunogenic in patients with SLE.
• Given the risk of potentially more severe presentations of
influenza in patients with SLE, yearly vaccination is
recommended.
•
31
32. Hepatitis B and C Virus Infection
• European League Against Rheumatism (EULAR) guidelines for
monitoring patients with SLE recommend screening of all
patients with specific risk factors for hepatitis B and C infection
at their first visit and serve as a useful guide for ensuring quality
of care in patients with SLE.
32
33. Myobacterium Tuberculosis
• The frequency of Mycobacterium tuberculosis (TB) infections in
patients with SLE in endemic countries is approximately 5%. TB
in SLE occurs commonly in extrapulmonary sites and may be
associated with more severe pulmonary involvement.
• In a study from California, 25% of SLE patients were found to
have latent TB infection.
• One of the most important risk factors for TB reactivation is
corticosteroid use.
•
33
34. American and Canadian guidelines
• Recommend that patients with prolonged therapy with
corticosteroids (prednisone >15 mg/day or equivalent for 2–4
weeks), who have a positive tuberculin skin test, indicating latent
TB infection, should be treated with preventive therapy.
• In endemic countries, use of isoniazid preventive therapy in
patients with rheumatic disease who are treated with prednisone
more than 15 mg/day for more than 3 months, independent of
tuberculin skin testing, can decrease the risk of developing TB
by 70%.
• Given the morbidity of TB, we recommend tuberculin skin testing
in patients from endemic areas prior to the initiation of
immunosuppressive therapy to identify patients with latent TB
infection who are candidates for INH preventive therapy.
34
35. Pneumocystis jiroveci
(Pneumocystis carinii)
• Is a common cause of pneumonia in immunosuppressed
individuals and is associated with a variety of immune deficits;
however, the main risk factors include cellular immune
deficiency resulting from corticosteroid and cytotoxic drug
therapy
• The attack rate of P jiroveci pneumonia (PJP) in patients with
connective tissue disease has been estimated at less than 2%,
although the exact incidence in SLE patients is difficult to
estimate.
• Infection occurred between 6 and 7 months after
immunosuppression had been initiated and had a mortality rate
of 20%. SLE patients infected with P jiroveci had a higher
disease activity and renal involvement was more common
35
36. Pneumocystis prophylaxis
• There is a higher rate of intolerance to TMP-SMX in SLE patients
with up to 52% of patients experiencing an adverse reaction,
usually cutaneous rashes.
• Sulfonamides may be associated with
– worsening SLE.
– risk of marrow suppression
– hemolysis and is not ideal in renal failure.
– hepatotoxicity, gastrointestinal intolerance and nephrotoxicity.
Lastly
• TMP-SMX may interact with a number of other immunosuppressive
medications including azathioprine, methotrexate and
mycophenolate mofetil and potentiate neutropenia
36
37. Pneumocystis
• Patients on at least 30 mg of prednisone daily are at higher risk
for pneumocystis and infection has been reported to occur after
a median of 12 weeks of therapy.
• Some experts recommended that PJP prophylaxis be
considered in patients on at least 16 mg of prednisone daily for
more than 8 weeks.
• Special consideration should be given to lupus patients who are
receiving combination therapy with prednisone and cytototoxic
agents such as cyclophosphamide.
37
38. Strongyloides stercoralis
• Is a nematode endemic in tropical and subtropical regions and it
infects up to 100 million people each year worldwide. Persons
chronically infected with S. stercoralis may be asymptomatic
• Disseminated strongyloidiasis has been described in patients
with SLE on immunosuppressive agents, especially
corticosteroids.
• The clinical presentation of the S. stercoralis hyperinfection
syndrome may be variable and may mimic some features of SLE
including pulmonary hemorrhage or vasculitis.
38
39. Srongiloides stercoralis
• It is recommended that patients from endemic areas (generally
tropical and subtropical areas) be screened with serologic
testing. Alternatively, microscopic evaluation of stool samples or
duodenal fluid for ova and parasites may yield positive results;
however, multiple samples may need to be obtained to
demonstrate infection.
• If infection is detected, Ivermectin should be prescribed to
eradicate infection.
39
40. Other Rare Infections
• Other rare opportunistic infections have been reported in SLE
patients including Mycobacterium avium
• Invasive fungal infections such as Cryptococcus
• Aspergillus and Candida species.
• No trials on prevention of these infections exist and diagnostic
vigilance is required.
40
41. Additional Strategies to Prevent
Infection
• Basic hygiene and sanitation including frequent hand washing
are the cornerstones of prevention of many infectious diseases
and bear mention.
• Judicious use of immunosuppressive therapy may lessen
infection risk.
• Interestingly, antimalarials may have protective effects against
infections, an observation which bears further study.
41
42. Conclusion
• Infections are a common cause of morbidity and
mortality in SLE and few guidelines exist on
preventing infections in SLE, especially
opportunistic infections.
42
43. A checklist to be utilized to identify
patients at risk
• Yearly influenza shot – give or recommend to family medical
doctor.
• Pneumococcal vaccination – give or recommend to family medical
doctor (every 5 years).
• Regular pap smears to screen for cervical dysplasia caused by
HPV – recommend to family medical doctor or gynaecologist.
There are currently no recommendations or data regarding the
use of the HPV vaccine in patients with SLE outside of
recommendations for the general population.
• TB skin test prior to starting immunosuppressive agents and
treatment with isoniazid (INH) for patients with latent TB infection.
43
44. Checklist
• Hepatitis B serology at baseline in all patients.
• Hepatitis C serology at baseline in patients with risk factors.
• HIV serology at baseline in patients with risk factors.
• Screening for strongyloides in patients from endemic areas
(strongyloides serology) prior to starting immunosuppressive
agents and treatment with ivermectin if infected.
• Vaccination against herpes zoster should also be considered
for patients with SLE who meet the criteria
44
47. Thank you
For your
participation in
Reumatologi Klinik Bandung
9-10 Feb 2013
Editor's Notes
Autoimmune diseases (AIDs) may be classified as organ-specific or systemic (non-organ-specific). There is a spectrum of AIDs including some that exhibit intermediate features.