Pathophysiolo gy and

Clinic al Sp e c trum of
I nfe c tions in Systemic
Lupus Er y thematosus
Raquel Cuchacovich, MDa,*, Abraham Gedalia, MDb

KEYWORDS
 Systemic lupus erythmatosus  Infections  Pathogenesis
 Immunosuppression  Immunodeficiencies

Systemic lupus erythematosus (SLE) is an inflammatory and multisystemic autoim-

mune disorder characterized by an uncontrolled autoreactivity of B and T lymphocytes
leading to the production of autoantibodies (auto-Abs) against self-directed antigens
and tissue destruction. The breakdown of tolerance, which is poorly understood, is the
main feature of the disease. It involves intrinsic and extrinsic mechanisms, such as
genes, deficiency of regulatory T/B cells, and hormonal and environmental factors
(Box 1).1–23
Several lines of evidence suggest that there is familial aggregation; a sibling of an
SLE patient is approximately 20 times more likely to develop disease. In a prospec-
tively followed cohort from South Sweden, 15% of the patients who had SLE had
a first-degree relative who had SLE. Twin studies support a concordance rate of
2% in dizygotic compared with 24% in monozygotic twins. Deficiencies in C1q
(>90% develop the disease), C2, C4, and CR1 receptor, and polymorphic variants of
the mannose binding lectin (MBL)–2 gene, and certain human leukocyte antigen
(HLA) class II haplotypes, such as DR2-DQ6, the extended haplotype HLA A1-B8-
DR3-DQ2-C4AQ0, and tumor necrosis factor (TNF) gene variants are associated.
Other polymorphic genes implicated are Fc-receptor genes IIa and IIIa, C-reactive
protein, programmed cell death-1 (PDCD-1), IL-1 receptor antagonist (Ra), chemo-
kines (CCL2), and genes being part of interferon (IFN) pathways.13,24–36
Environmental factors, such as infections, which are an important cause of
morbidity and mortality, hormones, smoking, alcohol intake, exposure to aromatic
amines, pesticides, silica, organic solvents, heavy metals, ultraviolet light, dietary

a
Section of Rheumatology, Department of Internal Medicine, Louisiana State University
Health Sciences Center, 1542 Tulane Avenue, New Orleans, LA 70112, USA
b
Department of Pediatrics, Louisiana State University Health Sciences Center, 1542 Tulane
Avenue, New Orleans, LA 70112, USA
* Corresponding author.
E-mail address: rcucha@lsuhsc.edu (R. Cuchacovich).

Rheum Dis Clin N Am 35 (2009) 75–93

doi:10.1016/j.rdc.2009.03.003 rheumatic.theclinics.com
0889-857X/09/$ – see front matter ª 2009 Elsevier Inc. All rights reserved.
76 Cuchacovich & Gedalia

Box 1
Impaired immune functions in systemic lupus erythematosus that may predispose to infection

Breakdown in the mechanisms that maintain T- and B-cell tolerance

Production of autoantibodies, which react with nuclear, cytoplasmic, cell membrane, and
extracellular matrix components; these immune complexes (IC) initiate inflammation and tissue
damage
Failure to remove autoreactive B cells: FcgRIIb induce cell death, inhibit migration, and control
plasma cell survival, which contribute to autoimmunity and infection
Posttranslational modifications of nuclear autoantigens, such as ubiquitination, citrullination,
phosphorylation, and methylation, result in the presentation of cryptic self-antigens
Significant lower level of CD241CD251 T reg cells
Decreased phagocytosis, clearance of apoptotic blebs, impaired nitroblue tetrazolium
reduction, and reduced production of interleukin (IL)–8 and IL-12 by polymorph nuclear cells
Inappropriate activation of toll-like receptor (TLR) for self-antigens, TLR3 (ds) RNA, TLR7 (ss)
RNA, and TLR9 (unmethylated CpG motifs within ssDNA)
TLR9 is expressed in B cells, dendritic cells (DCs), and macrophages, recognizes bacterial DNA
with multiple CpG nucleotides; and co-ligation of the B cell receptor and TLRs induces
proliferation and differentiation of plasmacytoid DC (pDC)
Internalization of mammalian DNA-containing IC in DCs is mediated by FcgRIIa, delivering the
antigen into lysosomes containing TLR9, which subsequently initiates DC activation and the
production of Type I IFNs
Clearance of IgG-coated erythrocytes and soluble IC is delayed because of reduced
complement- and Fc-mediated uptake
Mannose-binding lectin deficiency may be a susceptibility for SLE and high frequency of
infections, particularly bacterial and mainly pulmonary

factors, such as alfalfa sprouts and saturated fats, and the drugs hydralazine, procai-
namide, estrogens, TNF-inhibitors, antiepileptics, sulfasalazine (SSZ), statins, and
type I IFN are potential triggers of the disease.37,38

BACTERIAL INFECTION

About 80% of SLE infections are caused by bacteria. The most frequent sites of infec-
tion are skin, respiratory tract, and urinary tract, accounting for more than two thirds of
the infections seen in SLE (Box 2).39–42
Depressed IL-12 production by polymorph nuclear cells (PMNs) in patients who
have SLE could be of significance in acute infections, such as bacterial pneumonia,
candidiasis, and urinary tract infection.43 Several risk factors predispose patients
who have lupus to infections, such as active disease, lymphopenia,44 presence of
renal involvement, immunosuppressive therapy, and central nervous system (CNS)
damage.45–48 Antigranulocyte antibodies, found in approximately 50% of patients
who have SLE, can cause neutropenia through direct cytotoxicity and opsonization.
Bosch and colleagues49 studied the incidence and characteristics of infection in
SLE, as well as the risks factors. A total of 110 patients who had SLE and 220 controls
were prospectively followed up over 3 years and all the infectious episodes were
recorded. Thirty-nine patients who had SLE experienced at least one infection
(36%) versus 53 controls (22%), (P<.05). The incidence of urinary infections, pneu-
monia, and bacteremia without known focus was significantly greater in SLE. Escher-
ichia coli was the most common microorganism (21.3%). In the univariate analysis,
 Infections in SLE 77

Box 2
Most frequent microorganisms found in patients who have systemic lupus erythematosus

Bacteria
Staphylococcus aureus
Nontyphoidal Salmonella
Escherichia coli
Streptococcus pneumoniae
Haemophilus influenzae
Klebsiella spp
Acinetobacter spp
Pseudomonas spp
Mycoplasma spp
Virus
Parvovirus B19
Cytomegalovirus
Epstein-Barr virus
Herpes simplex/varicella zoster
Human papillomavirus
Hepatitis A
Fungus
Candida spp
Aspergillus spp
Cryptococcus neoformans
Nocardia spp
Mycobacterium
Nontuberculous mycobacterium
Mycobacterium chelonae
M avium complex (MAC)
M haemophilum
M fortuitum
M marinum
M tuberculosis

nephritis, SLE activity, leukopenia, anti-dsDNA Abs, low CH50, and ever use of
steroids or cyclophosphamide were significantly associated with infection. In the
multivariate analysis, total serum complement levels and a daily dose of prednisone
greater than 20 mg during at least 1 month plus use of cyclophosphamide were found
to be significant (P<.0001). Hypocomplementemia seems to be an independent
predictive factor for infection (Box 3). Hsieh and colleagues50 demonstrated that
anti-SSB/La antibodies cause increased neutrophil apoptosis, IL-8 production, and
decreased phagocytosis. Biswas and colleagues51 assessed the phagocytic effi-
ciency of PMNs in patients who had SLE with and without history of infections and
78 Cuchacovich & Gedalia

Box 3
Systemic lupus erythematosus risk factors that predispose to infections

Active disease
Long-term disease damage
Cytopenias (neutropenia/lymphopenia)
Hypocomplementemia
Renal involvement
CNS involvement
Immunosuppressive therapy

correlated it with disease activity, duration, and presence of anti-SSB/La antibodies.

They also analyzed the ability of PMNs from patients who had SLE to produce IL-12
in response to LPS with or without IFN-g. Findings showed that PMNs from patients
who have SLE have impaired phagocytic efficiency and decreased production of IL-
12, which is more pronounced in patients who have a history of infections, and the
phagocytic efficiency is significantly lower in patients who are anti-SSB/La positive.52
A study on adult patients who had SLE in Hong Kong revealed that infections
accounted for 60% of mortality, followed by cardiovascular (12%) and cerebrovas-
cular (16%) diseases. Bacteremia is common in patients who have SLE and bacter-
emia-related mortality is higher than mortality caused by other infections. The
prevalence of bacteremia in patients who have SLE fluctuates between 16% and
47% and is mainly caused by opportunistic pathogens and microorganisms that are
responsible for common infections in the general population. Mok and colleagues53,54
indicated that age is an important factor that affects the clinical manifestations and
prognosis of SLE and that infection is a major cause of mortality in late-onset SLE.
Multiple studies have identified that active lupus is one of the risk factors for infec-
tion; in the Toronto study, patients who had SLE who developed infections required
longer hospitalization (28.5 versus 11.2 days, P<.001) and had higher SLE Disease
Activity Index (SLEDAI) scores (11.6 versus 7.1). A prospective study in the Hopkins
Lupus Cohort55 also demonstrated that SLE activity (SLEDAI) was a predictive factor
for hospitalization because of infection. Gram-negative bacilli are the most common
microorganisms responsible for bacteremia in Asian patients who have SLE, but
Gram-positive coccid are more often encountered in Western patients who have
bacteremic SLE. Nontyphoidal salmonella is the main cause of Gram-negative bacter-
emia in patients who have SLE.56–59 In immunocompromised patients, the overall
mortality of salmonella bacteremia has been reported as 26%. Chen and colleagues56
described the nature of bacteremia in patients who have SLE and determined the
short-term survival and long-term outcome of these patients. They analyzed medical
records of 1442 patients who had SLE who were regularly followed up in a tertiary
teaching medical center for a 6-year observation period. Among 1442 patients who
had SLE, 240 patients (17%) developed at least one episode of bacteremia, corre-
sponding to an incidence of 92.7 cases/1000 hospital admissions. Since SLE diag-
nosis, the overall survival of their patients was 92% at 5 years, 86% at 10 years and
79% at 15 years. After one episode of bacteremia, however, the survival decreased
to 76% at 30 days and 67% at 360 days. Of the 336 episodes of bacteremia, 167
were community acquired (49.7%) and 169 were nosocomial (50.3%). Staphylo-
coccus aureus was the leading cause of Gram-positive bacteremia. Among Gram-
negative bacteria, nontyphoidal salmonella and E coli were the most common species.
 Infections in SLE 79

Community-acquired salmonella and streptococcus bacteremia were more common

than nosocomial infections. Klebsiella and Acinetobacter spp were significantly more
responsible for nosocomial than community-acquired bacteremia. Patients infected
with Acinetobacter, Klebsiella, or Pseudomonas had lower probabilities of 14-day
survival (71.4%, 55.6%, and 42.9%, respectively). There was a significant difference
in the SLEDAI scores between patients who developed bacteremia infection and those
who did not. Use of oral corticosteroids was more common in patients who developed
bacteremia. There were no significant differences between the two groups in the use
of other immunosuppressants (methylprednisolone pulse therapy, azathioprine [AZA],
or cyclophosphamide).60
Risk factors for long-term disease damage in juvenile-onset SLE are disease dura-
tion, cumulative disease activity, neuropsychiatric lupus, acute thrombocytopenia,
hypertension, seropositivity for antiphospholipid antibody, corticosteroid and cyclo-
phosphamide therapy, renal involvement, duration of AZA, and recurrent infections.
In a retrospective study Lee and colleagues61 analyzed the pattern of infections and
disease damage that occurred in a cohort of patients who had juvenile-onset SLE;
the second endpoint was whether cumulative disease damage was associated with
recurrent infections in these patients. Thirty-two (68.1%) patients had lupus nephrop-
athy and 16 patients (34%) had neuropsychiatric lupus. Sixty-one episodes of major
infections, defined as infections requiring more than 1 week of antimicrobial agents,
occurred in 27 patients (57.4%), and 18 patients (31.4%) had recurrent major infec-
tions (two episodes). Organ damage using the Systemic Lupus International Coll-
aborating Clinics/American College of Rheumatology Damage Index (SDI) was
documented in 21 subjects (44.7%). The occurrence of major infections (P<.001)
was the only significant risk factor for disease damage. There was a positive correla-
tion between SDI score with the number of recurrent major infections (P<.001). This
study showed that long-term disease damage and recurrent infections were a signifi-
cant burden to patients who had juvenile-onset SLE despite good overall survival.
Lupus nephritis, duration of use of AZA, and the occurrence of major infections
were significantly more common in patients who had long-term damage.62 Rojas-
Serrano and colleagues63 assessed the prevalence of infections in patients who had
SLE with pulmonary hemorrhage. Fourteen events in 13 patients were evaluated. In
eight (57%), infection was demonstrated; the most common pathogenic agents
were Pseudomonas spp and Aspergillus fumigatus. Four patients died, 3 of them of
pulmonary infection and 1 of a cerebral hemorrhage secondary to severe
hypertension.

VIRAL INFECTIONS IN SYSTEMIC LUPUS ERYTHEMATOSUS

Acute viral infections in children and adults induce transient autoimmune responses,
including generation of autoantibodies in low titers with a transient course, but the
progression into an established autoimmune disease is rare.64,65 The most common
viral infections in patients who have SLE are parvovirus B19 (there are more than 30
reports of primary B19 infection reported as lupus-like syndrome)66–70 and cytomeg-
alovirus (CMV, predominantly presenting in severely immunosuppressed patients).
CMV infection may mimic a lupus flare or present with specific organ involvement,
such as gastrointestinal bleeding or pulmonary infiltrates. Ramos-Casals and
colleagues71 studied the cause and clinical features of acute viral infections in 88
(23 from their clinics and 65 from the literature review) patients who had SLE and their
influence on the diagnosis, prognosis, and treatment. Twenty-five patients were diag-
nosed with new-onset SLE associated with infection by human parvovirus B19
80 Cuchacovich & Gedalia

(n 5 15), CMV (n 5 6), Epstein-Barr virus (EBV; n 5 3), and hepatitis A virus (n 5 1). The
remaining 63 cases of acute viral infections arose in patients already diagnosed with
SLE. In 18 patients symptoms related to infection mimicked a lupus flare; 36 patients,
including 1 patient from the former group who presented with both conditions, pre-
sented organ-specific viral infections (mainly pneumonitis, colitis, retinitis, and hepa-
titis). Ten patients had a severe multiorgan process similar to that described in
catastrophic antiphospholipid syndrome; the final diagnosis was hemophagocytic
syndrome in 5 cases and disseminated viral infection in 5 cases. Twelve patients
died of infection caused by CMV (n 5 5), herpes simplex virus (n 5 4), EBV (n 5 2),
and varicella-zoster virus (VZV; n 5 1). Autopsies were performed in 9 patients and dis-
closed disseminated herpetic infection in 6 patients (caused by herpes simplex in
4 cases, varicella in 1, and CMV in 1) and hemophagocytic syndrome in 3. A higher
frequency of renal failure (54% versus 19%, P 5 .024), antiphospholipid syndrome
(33% versus 6%, P 5 .023), treatment with cyclophosphamide (82% versus 37%,
P 5 .008), and multisystemic involvement at presentation (58% versus 8%, P<.001),
and a lower frequency of antiviral therapy (18% versus 76%, P<.001) were found in
patients who died, compared with survivors.72
Some viral infections, especially CMV and B19 but also EBV, varicella, hepatitis A
virus, norovirus, measles, and mumps, can mimic lupus flares in patients who have
SLE. Fever, arthralgia, malaise, cutaneous rash, lymphadenopathy, and cytopenia
and could be easily confused with a lupus flare. In patients who have SLE with a sus-
pected flare who do not respond to SLE-specific therapy, careful evaluation of virus-
specific features (elevated transaminases for hepatitis A virus, acute onset of diarrhea
and vomiting for norovirus, cutaneous vesicular rash for varicella, and parotid enlarge-
ment for mumps), together with investigations for the most frequent viruses involved
(herpesviruses and B19), should be performed.67,73,74
Patients who have SLE with acute viral infections often present comorbid processes
that may complicate the diagnosis and outcome, such as severe cytopenias, throm-
bocytopenia, leukopenia, hemolytic anemia, pure red cell aplasia, and hemophago-
cytic syndrome.75–82 Disseminated viral infections (associated with hemophagocytic
syndrome or not) should be included in the differential diagnosis of life-threatening
situations (of which catastrophic antiphospholipid syndrome [APS] is the main differ-
ential diagnosis) in patients who have SLE. Parvovirus B19 mainly affects patients who
are not immunosuppressed and mimics SLE, whereas CMV preferentially affects im-
munosuppressed patients.

Epstein-Barr Virus
EBV is a member of the herpesvirus family, causes acute infectious mononucleosis
and lymphoproliferative diseases, and triggers the development of autoimmune
diseases. In 1971 Evans83 described a high prevalence of the virus in the sera of
patients who had SLE, and in 1997 EBV was proposed as an etiologic cause for
SLE, rather than an incidental finding. The pathogenesis is molecular mimicry,
between EBV antigen 1 and lupus-specific antigens, such as Ro, La, or dsDNA,
through induction of TLR hypersensitivity by EBV latent membrane protein 2A or by
creating immortal B and T cells by loss of apoptosis. Pender and colleagues84 state
that during primary infection, autoreactive B cells are infected by EBV, proliferate,
and become latently infected memory B cells, which are resistant to apoptosis as
a consequence of expression of virus-encoded antiapoptotic molecules. Then autor-
eactive T cells, which were activated by the impaired B cells, also fail to undergo
apoptosis because they receive a costimulatory survival signal from the infected B
cells. The autoreactive T cells proliferate and produce cytokines, which recruit other
 Infections in SLE 81

inflammatory cells, with resultant target-organ damage and chronic autoimmune

disease.85–93

Cytomegalovirus
CMV, a member of the herpesvirus family, has a potential role in the development and
progression of SLE. There seems to be a higher prevalence of CMV IgG and IgM anti-
bodies in patients who have SLE, antiphospholipid syndrome, primary biliary cirrhosis,
systemic sclerosis, polymyositis, Sjögren syndrome, and vasculitis. CMV may
produce a systemic infection mimicking SLE, either superimposed upon a flare or pre-
senting with isolated organ involvement that may not be immediately attributable to
infection (gastrointestinal bleeding from colitis or pulmonary infiltrates from pneumo-
nitis).94–99

Varicella–Zoster Virus
Following primary infection, VZV is latent in the cranial nerve ganglia or the dorsal root
ganglia throughout its lifetime. VZV infection is common among patients who have
SLE, but disseminated or aggressive episodes are rare. In Kahl’s study,100 dissemi-
nated infections accounted for 11% of episodes, but this experience is not confirmed
by other authors. Moga and colleagues101 followed 145 patients who had SLE for
a mean period of 7.6 years. They detected 20 VZV infections in 19 patients (13.1%)
with no disseminated episode among them. Higher incidence was in patients under
immunosuppressive therapy or corticosteroids. There was no evidence of a delete-
rious effect of VZV infection on SLE evolution and patients responded to established
therapy. In a retrospective study Hellman and colleagues102 reviewed the charts of 44
patients who had SLE who died during the hospital admission. A total of 24 of 44 (55%)
of the patients had an infection and in 13 of those 24 (50%) infection was the cause of
death, but only 1 patient presented with disseminated herpes zoster. Corticosteroids
are a risk factor for VZV infections; most infections appear in patients who take daily
doses of prednisone less than 20 mg or in patients not taking any prednisone.

Human Papillomavirus
Women who have SLE are at enhanced risk for acquiring HPV-16 infections and devel-
oping cervical premalignancies.103,104 Women in the United Kingdom who had a recent
SLE diagnosis had elevated levels of HPV infections (European HPV-16 variants at
a high viral load), abnormal cervical cytology, and squamous intraepithelial lesions
(SIL). Previous studies of HPV infections among patients who had SLE have demon-
strated that wart-virus antibodies are less frequent among patients than controls, sug-
gesting an inability to produce an effective immune response to HPV, and that 11% of
patients had high-risk HPV infections, which are not associated with therapy.105,106
Nath and colleagues107 studied the rates of HPV infections, abnormal cervical smears,
and SIL in 30 women in the United Kingdom who had SLE and compared them with 67
abnormal smears from colposcopy clinics, and 15 community subjects who had
normal smears. SLE and colposcopy patients were more likely (P<.05) to be HPV posi-
tive (15 [54%] and 37 [67%] patients, respectively) and HPV-16 DNA positive (16 [57%]
and 17 [31%] patients, respectively) than community subjects (0% HPV DNA positive
and 1 [6%] HPV-16 DNA positive). SLE patients were also more likely to be HPV-16
DNA positive than colposcopy patients (P<.05). Patients who had SLE with a high
HPV-16 viral load more frequently had SIL (n 5 6) than those who had a low HPV-
16 viral load (n 5 1; P<.05). HPV and HPV-16 DNA positivity were not associated
82 Cuchacovich & Gedalia

with previous or current drug therapy for patients who had SLE. Eighteen (60%)
patients who had SLE had a previous or current cervical abnormality. At the time of
study, 5 (17%) patients who had SLE had an abnormal cervical smear and 8 (27%)
had SIL. For those diagnosed with SLE for greater than 10 years, the rate of SIL
was 44% lower than those who had SLE for less than 5 years (odds ratio 0.56, 95%
confidence interval 0.1–3.5). The results demonstrated that patients who have SLE
are at significantly heightened risk for HPV-16 infections and for developing cervical
abnormalities, particularly SIL.

OPPORTUNISTIC MICROORGANISMS
Fungal Infections
Cases of SLE with fungemia or invasive fungal infection have seldom been described.
During the past 35 years, only case reports (the largest consisting of three cases) have
described fungal infections in patients who had SLE. Sieving and colleagues108
reported three SLE cases who had deep fungal infections and reviewed 30 cases in
the literature; most patients were young females. Among these 30 patients, the
most common infection was Candida spp (n 5 13), C neoformans in 10 and Aspergillus
spp in 4. Candida infection was identified as the most common fungal infection.109 In
contrast, cryptococcal infection was the most common pathogen in this study. Nocar-
dial infections are common fungal infections in steroid-treated patients who have SLE,
particularly for lung lesions.110–114 Severe candida infection is the most frequently
identified opportunistic fungal infection in several SLE series, associated with steroid
and cytotoxic drug therapy. Patients who had fungal infections had active SLE (SLE-
DAI > 7), indicating that SLEDAI greater than 7 may be a predisposing factor for fungal
infection. In this study, survival was 80% at 1 year (SLE diagnosis to death) for patients
who had SLE who were suffering fungal infections, 73.3% at 2 years, 66.7% at 5 years
and 60% at 10 years. Patients who had SLE with fungal infections in this study had
poorer prognosis than the general SLE population. Currently there is no consensus
as to whether different corticosteroid doses predispose patients to fungal infection
regardless of earlier lupus involvement (such as hemolytic anemia or positive anticar-
diolipin antibody) in patients who have SLE.
Chen and colleagues115 studied invasive fungal infections in 15 Taiwanese patients
who had SLE and compared the characteristics of their infections with those reported
in the literature. Cryptococcus neoformans was the most commonly identified fungus
in this Taiwanese series. The prevalence of autoimmune hemolytic anemia and posi-
tive results for the anticardiolipin antibody in this study were significantly higher than
those in patients who had SLE in general (P<.0001 and P<.0001, respectively). Fungal
infection contributed to cause of death in 7 of 15 (46.7%) patients; C neoformans
accounted for 6 of these infections. Low-dose prednisolone (<1 or <0.5 mg/kg/d based
on arbitrary division) before fungal infection tended to correlate with 1-year mortality
after diagnosis of SLE (P 5 .077 or P 5 .080). Following fungal infection, however,
patients who died of infection itself had been prescribed with higher prednisolone
dose or equivalent than surviving patients (P 5 .016). All patients who had SLE who
had fungal infections had active SLE (SLEDAI > 7). C neoformans infection accounted
for most fatalities in patients who had SLE with fungal infections in this series. Active
lupus disease is probably a risk factor for fungal infection in patients who have SLE.
Notably, low prednisolone doses before fungal infection or high prednisolone doses
following fungal infection tended to associate with or correlated to fatality,
respectively.
 Infections in SLE 83

MYCOBACTERIAL INFECTIONS

Nontuberculous mycobacterium (NTM) infections have been described in patients

who have autoimmune diseases in isolated case reports, especially in those who
have SLE.116–119 Mok and colleagues120 examined the clinical manifestations of
NTM infections with those of M tuberculosis (MTB) infections in 725 patients who
had SLE. Eleven cases were identified (prevalence 1.5%). The mean  SD age at
the time of infection was 42.8  13.9 years, 9.3  5.8 years after the onset of SLE.
The mean  SD time taken from onset of symptoms to the diagnosis of NTM infection
was 5.7  7.2 months. Sites of involvement included skin and soft tissue (n 5 8), chest
(n 5 2), and disseminated infection (n 5 1). NTM infections were more likely to involve
extrapulmonary sites (soft tissue and skin) (P 5 .006), presented in patients with longer
lupus disease duration (P<.001), and occurred in older patients (P<.001) and in those
who had a higher cumulative dose of prednisolone (P 5 .01) than MTB infections.
Disease duration was found to be the only independent predictive factor (P 5 .005)
for NTM infections. Ten (25.6%) patients who had MTB infections but none of
the patients who had NTM infections presented concomitantly at the onset of SLE
(P 5 .09). MTB occurred in 33.3% of our cohort and may manifest as synovitis, skin
ulcer, and lymphadenitis. There were no differences in the recurrence rate (P 5 .64)
and frequency of disseminated infections (P 5 .40) between NTM and MTB infections.
NTM infections tended to develop in patients who had SLE later in their disease
course than MTB infections. Local implantation of the organism from skin abrasion
is likely to be the route of transmission, because most NTM are found in water and
soil. M chelonae viz M avium complex (MAC) and M haemophilum cause cutaneous
infections in SLE.121 In acute synovitis, mainly monoarticular involvement and periar-
ticular tissue, M fortuitum, MAC, and M marinum have been found.122–126
MTB infection occurs earlier in the clinical course of SLE than NTM infection. Most
NTM that causes disease involve the lungs, skin, soft tissue, lymph node, and bone,
and rarely disseminate. NTM presentation may be insidious in onset, have different
sites of involvement, and present as multifocal lesions. Tissue culture is often required
for a definitive diagnosis because the clinical manifestations of NTM infections are not
pathognomonic and may mimic other infective or noninfective conditions. NTM infec-
tions tend to occur in the chronically and more heavily immunosuppressed patients
who have SLE as compared with tuberculosis.127

IS THERE ANY ASSOCIATION BETWEEN IMMUNOSUPPRESSIVE THERAPY AND INCREASED

MORBIDITY AND MORTALITY DUE TO INFECTIONS IN SYSTEMIC LUPUS ERYTHEMATOSUS?

The use of immunosuppressive therapies in SLE carries a significantly increased risk

for developing infections, especially in patients treated with high-dose corticosteroids
and cyclophosphamide. Infections in immunosuppressed patients are usually caused
by bacteria, but patients may also develop severe viral infections. Patients who had
viral infections who had received cyclophosphamide had a poorer survival. Staples
and colleagues128–130 suggested that the incidence of infection among patients who
had SLE increased when steroid dose increased, whereas disseminated or deep
tissue infections occurred more frequently in patients who had azotemia receiving
high doses of steroids. In a study by Petri and Genovese,55 hospitalized patients
who had SLE received a mean prednisone dose of more than 10 mg significantly
more commonly compared with nonhospitalized patients. The mean prednisone
dose was not found to be significantly different between patients who had SLE who
developed infections and those who did not in two other studies. In another study,
the median prednisolone dose was not found to be significantly different between
84 Cuchacovich & Gedalia

patients who had SLE who developed three or more bacterial infections other than
urinary tract infections and those who did not have SLE. Recent administration of
methylprednisolone pulse was outlined as a risk factor for infection in another study.
Prolonged treatment with corticosteroids was found to be more common among
patients who had SLE who had more than two bacterial infections (other than urinary)
compared with those who did hot have such infections in another study. Rosner and
colleagues131 reported that deaths attributable to infections were statistically signifi-
cant related only to the peak of steroid dose without any correlation with other immu-
nosuppressants used. Petri and Genovese55 reported that even though patients who
had infections were treated with higher doses of prednisone, this relation was not
statistically significant.

IMMUNODEFICIENCIES IN SYSTEMIC LUPUS ERYTHEMATOSUS

Common Variable Immunodeficiency
Hypogammaglobulinemia in SLE may occur as part of common variable immunodefi-
ciency (CVID).132–136 Patients who have CVID develop recurrent respiratory and sinus
infections; a subset of these patients can also develop features suggestive of immune
dysregulation, including autoimmunity (usually cytopenias and SLE); granulomatous
inflammation, which can affect liver, spleen, and lungs; and bowel disease. Transition
from one state to the other is clearly unusual.137,138 Whether these two entities just
coexist or CVID is a complication of SLE or is caused by the immunosuppressive treat-
ment given for controlling the autoimmune disease is an open question.
CVID has been described in patients after the diagnosis of SLE; immunosuppressive
agents, such as cyclophosphamide, AZA, mycophenolate mofetil, SSZ, long-term
low-dose corticosteroids, and repeated courses of rituximab, had been used for treat-
ment of SLE before detection of hypogammaglobulinemia. Drug-induced hypogam-
maglobulinemia is potentially reversible with cessation of therapy, unlike CVID,
although the duration of post-cessation hypogammaglobulinemia can be prolonged.
Ferna ndez-Castro and colleagues139 reviewed 18 SLE-associated CVID cases and
identified clinical characteristics and laboratory features in these patients. In 50% of
patients CVID developed within the first 5 years after the diagnosis of SLE. All patients
had been treated with corticosteroids and 72% had also received immunosuppressive
therapy. Sinopulmonary infections were the most frequent symptom. SLE disease
activity decreased after the development of CVID in 67% of patients. Most patients
(89%) were treated with gamma globulin therapy. In 60% of the patients there was
a reduced number or percentage of B cells.
CVID should be suspected in any patient who has SLE with recurrent sinopulmonary
infections in the absence of SLE activity or immunosuppressive treatment. Although
SLE-associated CVID is uncommon, because of its potentially fatal outcome it should
be considered in any patient who has SLE with hypogammaglobulinemia (at least 2
standard deviations below the mean for age in serum concentration of IgG and IgA),
poor or absent response to immunization (twofold or less increase in antibody titer),
and acute, chronic, or recurrent infections, specifically, pneumonia, bronchitis, sinus-
itis, conjunctivitis, and otitis. The clinical and bacteriologic spectrums of infections in
patients who have SLE who develop CVID do not seem to be significantly different
from those of patients who have SLE in the absence of CVID. The deficiency in IgG
production leads to recurrent infections with encapsulated organisms, including
Streptococcus pneumoniae and Haemophilus influenzae; there is also an unusual
susceptibility to mycoplasma infections. Chronic or recurrent conjunctivitis is mainly
due to nonencapsulated H influenzae. Bacterial meningitis and sepsis are also
 Infections in SLE 85

common. Unusual or opportunistic infections with viral and fungal pathogens have
been reported. Patients may have an increased susceptibility to enterovirus infection,
either presenting with classical meningoencephalitic symptoms or more rarely with
cognitive impairment that may be misdiagnosed. Arthritis may be a prominent feature
in adults who have CVID. Mycoplasma species, such as M pneumoniae, M salivarium,
and M hominis, and Ureaplasma urealyticum are the most common causes of septic
arthritis. The more characteristic, aseptic form of arthritis developing in individuals
who have CVID is symmetric, nonerosive polyarthritis of the large joints. Chronic
lung disease, specifically the development of bronchiectasis, liver dysfunction with
hepatitis B and C virus infection, primary biliary cirrhosis, and granulomatous disease,
have also been reported.

IgA Deficiency
Rankin and colleagues140 investigated the occurrence of IgA deficiency in SLE and
reported a prevalence of 5% in 96 patients who had SLE. Cassidy and colleagues141
estimated the prevalence of IgA deficiency at 2.6% in adults (n 5 152) and 5.2% in
children (n 5 77) who had SLE. These patients have a similar clinical course compared
with patients who have SLE without IgA deficiency.

IgM Deficiency
Selective IgM deficiency has been described in patients who have SLE and there is
a suggestion that it correlates with more severe or long-standing SLE.142–146 They
have recurrent sinopulmonary infections that respond to conventional courses of anti-
biotics without the need for prolonged antibiotic course or intravenous immunoglob-
ulin (Ig) therapy. Other unrelated causes of hypogammaglobulinemia in patients who
have SLE are lymphoproliferative disorders, including myeloma, chronic lymphocytic
leukemia, and lymphoma.

IMMUNIZATIONS

SLE exacerbation and onset with pneumococcal vaccination, tetanus toxoid, H influ-
enza B vaccines, and vaccinations for hepatitis B and influenza have been
described.147–149 Autoimmune phenomena have been observed in response to
measles, mumps, and rubella, and bacille Calmette-Gue rin vaccinations. In the Caro-
lina Lupus Study, there seemed to be no association between hepatitis B vaccination
and SLE. Whether there is truly an association between immunizations and incident
SLE is not well known, however. Possible mechanisms are molecular mimicry and
the host type I IFN response (initiation and flares).150

REFERENCES

1. Uccellini MB, Busconi L, Green NM, et al. Autoreactive B cells discriminate

CpG-rich and CpG-poor DNA and this response is modulated by IFN-alpha.
J Immunol 2008;181(9):5875–84.
2. Nakou M, Knowlton N, Frank MB, et al. Gene expression in systemic lupus eryth-
ematosus: bone marrow analysis differentiates active from inactive disease and
reveals apoptosis and granulopoiesis signatures. Arthritis Rheum 2008;58(11):
3541–9 IFN.
3. Cooper GS, Gilbert KM, Greidinger EL, et al. Recent advances and opportunities
in research on lupus: environmental influences and mechanisms of disease.
Environ Health Perspect 2008;116(6):695–702.
86 Cuchacovich & Gedalia

4. Wu P, Wu J, Liu S, et al. TLR9/TLR7-triggered downregulation of BDCA2 expres-

sion on human plasmacytoid dendritic cells from healthy individuals and lupus
patients. Clin Immunol 2008;129(1):40–8.
5. He B, Qiao X, Cerutti A. CpG DNA induces IgG class switch DNA recombination
by activating human B cells through an innate pathway that requires TLR9 and
cooperates with IL-10. J Immunol 2004;173(7):4479–91.
6. Mozaffarian N, Wiedeman AE, Stevens AM. Active systemic lupus erythemato-
sus is associated with failure of antigen-presenting cells to express programmed
death ligand-1. Rheumatology 2008;47(9):1335–41.
7. Takeuchi T, Tsuzaka K, Abe T, et al. T cell abnormalities in systemic lupus eryth-
ematosus. Autoimmunity 2005;38(5):339–46.
8. Know SK, Lee JY, Park SH, et al. Dysfunctional interferon alpha production by
peripheral plasmacytoid dendritic cells upon Toll-like receptor 9 stimulation in
patients with lupus erythematosus. Arthritis Res Ther 2008;10(2):R29.
9. Sawalha AH, Jeffries M, Webb R, et al. Defective T-cell ERK signaling induces
interferon-regulated gene expression and overexpression of methylation-sensi-
tive genes similar to lupus patients. Genes Immun 2008;9(4):368–78.
10. Lee HY, Hong YK, Yun HJ, et al. Altered frequency and migration capacity of
CD41CD251 regulatory T cells in systemic lupus erythematosus. Rheumatology
2008;47(6):789–94.
11. Munoz LE, van Bavel C, Franz S, et al. Apoptosis in the pathogenesis of
systemic lupus erythematosus. Lupus 2008;17(5):371–5.
12. Komatsuda A, Wakui, Iwamoto K, et al. Up-regulated expression of Toll-like
receptors mRNAs in peripheral blood mononuclear cells from patients with
systemic lupus erythematosus. Clin Exp Immunol 2008;152(3):482–7.
13. Pan F, Tang X, Zhang K, et al. Genetic susceptibility and haplotype analysis
between Fcg receptor IIB and IIIA gene with systemic lupus erythematosus in
Chinese population. Lupus 2008;17(8):733–8.
14. Anolik JH. B cell biology and dysfunction in SLE. Bull NYU Hosp Jt Dis 2007;
65(3):182–6.
15. Parietti V, Chifflot H, Muller S, et al. Regulatory T cells and systemic lupus eryth-
ematosus. Ann N Y Acad Sci 2007;1108:64–75.
16. Pickering MC, Macor P, Fish J, et al. Complement C1q and C8b deficiency in an
individual with recurrent bacterial meningitis and adult-onset systemic lupus
erythematosus-like illness. Rheumatology 2008;47(10):1588–9.
17. Wenger ME, Bole GG. Nitroblue tetrazolium dye reduction by peripheral leuko-
cytes from patients with rheumatoid arthritis and systemic lupus erythematosus
measured by a histochemical and spectrophotometric method. J Lab Clin Med
1973;82:513–21.
18. Su K, Yang H, Li X, et al. Expression profile of FcgRIIb on leukocytes and its dys-
regulation in systemic lupus erythematosus. J Immunol 2007;178:3272–80.
19. Clatworthy MR, Willcocks L, Urban J, et al. Systemic lupus erythematosus asso-
ciated defects in the inhibitory receptor Fc gR IIb reduce susceptibility to
malaria. Proc Natl Acad Sci U S A 2007;104:7169–74.
20. Mok MY, Ip WK, Lau CS, et al. Mannose-binding lectin and susceptibility to
infection in Chinese patients with systemic lupus erythematosus. J Rheumatol
2007;34(6):1270–6.
21. Truedsson L, Bengtsson AA, Sturfelt G. Complement deficiencies and systemic
lupus erythematosus. Autoimmunity 2007;40(8):560–6.
22. Alvarado-Sanchez B, Hernandez-Castro B, Portales-Perez D, et al. Regulatory T
cells in patients with systemic lupus erythematosus. J Autoimmun 2007;27:110–8.
 Infections in SLE 87

23. Monticielo OA, Mucenic T, Xavier RM, et al. The role of mannose-binding lectin in
systemic lupus erythematosus. Clin Rheumatol 2008;27(4):413–9.
24. Rhodes B, Vyse TJ. The genetics of SLE: an update in the light of genome-wide
association studies. Rheumatology 2008;47(11):1603–11.
25. Pickering MC, Botto M, Taylor PR, et al. Systemic lupus erythematosus, comple-
ment deficiency, and apoptosis. Adv Immunol 2000;76:227–324.
26. Tsutsumi A, Takahashi R, Sumida T. Mannose binding lectin: genetics and auto-
immune disease. Autoimmun Rev 2005;4(6):364–72.
27. Mamtani M, Rovin B, Brey R, et al. CCL3L1 gene-containing segmental duplica-
tions and polymorphisms in CCR5 affect risk of systemic lupus erythaematosus.
Ann Rheum Dis 2008;67(8):1076–83.
28. Jonsen A, Bengtsson AA, Nived O, et al. Gene-environment interactions in the
aetiology of systemic lupus erythematosus. Autoimmunity 2007;40(8):613–7.
29. Namjou B, Kilpatrick J, Harley JB. Genetics of clinical expression in SLE. Auto-
immunity 2007;40(8):602–12.
30. Brown EE, Edberg JC, Kimberly RP. Fc receptor genes and the systemic lupus
erythematosus diathesis. Autoimmunity 2007;40(8):567–81.
31. Gergely P Jr, Isaak A, Szekeres Z, et al. Altered expression of Fcg and comple-
ment receptors on B cells in systemic lupus erythematosus. Ann N Y Acad Sci
2007;1108:183–92.
32. Sestak AL, Nath SK, Sawalha AH, et al. Current status of lupus genetics. Arthritis
Res Ther 2007;9(3):210.
33. Kyogoku C, Tsuchiya N. A compass that points to lupus: genetic studies on type
I interferon pathway. Genes Immun 2007;8(6):445–55.
34. Brownlie RJ, Lawlor KE, Heather A, et al. Distinct cell-specific control of autoim-
munity and infection by FcgRIIb. J Exp Med 2008;205(4):883–95.
35. Crocker JA, Kimberly RP. Genetics of susceptibility and severity in systemic
lupus erythematosus. Curr Opin Rheumatol 2005;17(5):529–37.
36. Garred P, Madsen HO, Halberg P, et al. Mannose-binding lectin polymorphisms
and susceptibility to infection in systemic lupus erythematosus. Arthritis Rheum
1999;42:2145–52.
37. Tsay GJ, Zouali M. Toxicogenomics – a novel opportunity to probe lupus suscep-
tibility and pathogenesis. Int Immunopharmacol 2008;8(10):1330–7.
38. Kelly JA, Kelley JM, Kaufman KM, et al. Interferon regulatory factor-5 is geneti-
cally associated with systemic lupus erythematosus in African Americans.
Genes Immun 2008;9(3):187–94.
39. Atzeni F, Bendtzen K, Bobbio-Pallavicini F, et al. Infections and treatment of
patients with rheumatic diseases. Clin Exp Rheumatol 2008;26(1 Suppl 48):
S67–73.
40. Amital H, Govoni M, Maya R, et al. Role of infectious agents in systemic rheu-
matic diseases. Clin Exp Rheumatol 2008;26(1 Suppl 48):S27–32.
41. Wucherpfennig KW. Structural basis of molecular mimicry. J Autoimmun 2001;
16:293–302.
42. Lehmann PV, Forsthuber T, Miller A, et al. Spreading of T-cell autoimmunity to
cryptic determinants of an autoantigen. Nature 1992;358:155–7.
43. Tsai CY, Wu TH, Yu CL, et al. Decreased IL-12 production by polymorphonuclear
leukocytes in patients with active systemic lupus erythematosus. Immunol Invest
2002;31:177–89.
44. Ng WL, Chu CM, Wu AK, et al. Lymphopenia at presentation is associated with
increased risk of infections in patients with systemic lupus erythematosus. QJM
2006;99(1):37–47.
88 Cuchacovich & Gedalia

45. Zandman-Goddard G, Berkun Y, Barzilai O, et al. Neuropsychiatric lupus and

infectious triggers. Lupus 2008;17(5):380–4.
46. Duffy KN, Duffy CM, Gladman DD. Infection and disease activity in systemic
lupus erythematosus: a review of hospitalized patients. J Rheumatol 1991;18:
1180–4.
47. Noel V, Lortholary O, Casassus P, et al. Risk factors and prognostic influence of
infection in a single cohort of 87 adults with systemic lupus erythematosus. Ann
Rheum Dis 2001;60:1141–4.
48. Fessler BJ. Infectious diseases in systemic lupus erythematosus: risk factors,
management and prophylaxis. Best Pract Res Clin Rheumatol 2002;16:281–91.
49. Bosch X, Guilabert A, Pallares L, et al. Infections in systemic lupus erythematosus:
a prospective and controlled study of 110 patients. Lupus 2006;15(9):584–9.
50. Hsieh S-C, Yu H-S, Lin W-W, et al. Anti-SSB/La is one of the antineutrophil auto-
antibodies responsible for neutropenia and functional impairment of polymor-
phonuclear neutrophils in patients with systemic lupus erythematosus. Clin
Exp Immunol 2003;131:506–16, 1999.
51. Biswas D, Mathias A, Dayal R, et al. Presence of antibodies to SSB/La is asso-
ciated with decreased phagocytic efficiency of neutrophils in patients with
systemic lupus erythematosus. Clin Rheumatol 2008;27(6):717–22.
52. Strandberg L, Ambrosi A, Espinosa A, et al. Interferon-alpha induces up-regula-
tion and nuclear translocation of the Ro52 autoantigen as detected by a panel of
novel Ro52-specific monoclonal antibodies. J Clin Immunol 2008;28(3):220–31.
53. Mok CC, Mak A, Chu WP, et al. Long-term survival in Southern Chinese patients
with systemic lupus erythematosus: a prospective study of all age-groups. Medi-
cine 2005;84:218–24.
54. Mok CC, Lee KW, Ho CTK, et al. A prospective study of survival and prognostic
indicators of systemic lupus erythematosus in a southern Chinese population.
Rheumatology 2000;39:399–406.
55. Petri M, Genovese M. Incidence of and risk factors for hospitalizations in
systemic lupus erythematosus: a prospective study of the Hopkins lupus cohort.
J Rheumatol 1992;19:1559–65.
56. Chen MJ, Tseng HM, Huang YL, et al. Long-term outcome and short-term
survival of patients with systemic lupus erythematosus after bacteraemia
episodes: 6-yr follow-up. Rheumatology 2008;47(9):1352–7.
57. Chiu KM, Lin TY, Chen JS, et al. Rupture of renal artery aneurysm due to Salmo-
nella infection in a patient with systemic lupus erythematosus. Lupus 2008;17(2):
135–8.
58. Huang JL, Hung JJ, Wu KC, et al. Septic arthritis in patients with systemic lupus
erythematosus: salmonella and nonsalmonella infections compared. Semin
Arthritis Rheum 2006;36(1):61–7.
59. van de Vosse E, Hoeve MA, Ottenhoff TH. Human genetics of intracellular infec-
tious diseases: molecular and cellular immunity against mycobacteria and
salmonellae. Lancet Infect Dis 2004;4:739–49.
60. Tsao CH, Chen CY, Ou LS, et al. Risk factors of mortality for salmonella infection
in systemic lupus erythematosus. J Rheumatol 2002;29:1214–8.
61. Lee PP, Lee TL, Ho MH, et al. Recurrent major infections in juvenile-onset
systemic lupus erythematosus—a close link with long-term disease damage.
Rheumatology 2007;46(8):1290–6.
62. Chen YS, Yang YH, Lin YT, et al. Risk of infection in hospitalized children with
systemic lupus erythematosus: a 10-year follow-up. Clin Rheumatol 2004;23:
235–8.
 Infections in SLE 89

63. Rojas-Serrano J, Pedroza J, Regalado J, et al. High prevalence of infections in

patients with systemic lupus erythematosus and pulmonary haemorrhage.
Lupus 2008;17(4):295–9.
64. Barzilai O, Ram M, Shoenfeld Y. Viral infection can induce the production of
autoantibodies. Curr Opin Rheumatol 2007;19(6):636–43.
65. Su BY, Su CY, Yu SF, et al. Incidental discovery of high systemic lupus erythema-
tosus disease activity associated with cytomegalovirus viral activity. Med Micro-
biol Immunol 2007;196(3):165–70.
66. Aslanidis S, Pyrpasopoulou A, Kontotasios K, et al. Parvovirus B19 infection and
systemic lupus erythematosus: activation of an aberrant pathway? Eur J Intern
Med 2008;19(5):314–8.
67. Sugimoto T, Tsuda A, Uzu T, et al. Emerging lupus-like manifestations in acute
parvovirus B19 infection. Clin Rheumatol 2008;27(1):119–20.
68. Pugliese A, Beltramo T, Torre D, et al. Parvovirus B19 and immune disorders.
Cell Biochem Funct 2007;25(6):639–41.
69. Seve P, Ferry T, Koenig M, et al. Lupus-like presentation of parvovirus B19 infec-
tion. Semin Arthritis Rheum 2005;34(4):642–8.
70. Narvaez Garcia F, Domingo-Domenech E, Castro-Bohorquez F, et al. Lupus-like
presentation of parvovirus B19 infection. Am J Med 2001;111:573–5.
71. Ramos-Casals M, Cuadrado MJ, Alba P, et al. Acute viral infections in patients
with systemic lupus erythematosus: description of 23 cases and review of the
literature. Medicine 2008;87(6):311–8.
72. Chung A, Fas N. Successful acyclovir treatment of herpes simplex type 2 hepa-
titis in a patient with systemic lupus erythematosus: a case report and meta anal-
ysis. Am J Med Sci 1998;316:404–7.
73. Suzuki T, Saito S, Hirabayashi Y, et al. Human parvovirus B19 infection during
the inactive stage of systemic lupus erythematosus. Intern Med 2003;42:538–40.
74. Barzilai O, Sherer Y, Ram M, et al. EBV and CMV in autoimmune diseases. Are
they truly notorious? A preliminary report. Ann N Y Acad Sci 2007;1108:567–77.
75. Fish P, Handgretinger R, Schaefer H. Pure red cell aplasia. Br J Haematol 2000;
111:1010–22.
76. Ideguchi H, Ohno S, Ishigatsubo Y. A case of pure red cell aplasia and systemic
lupus erythematosus caused by human parvovirus B19 infection. Rheumatol Int
2007;27:411–4.
77. Isome M, Suzuki J, Takahashi A, et al. Epstein-Barr virus-associated hemopha-
gocytic syndrome in a patient with lupus nephritis. Pediatr Nephrol 2005;20(2):
226–8.
78. Kawashiri S, Nakamura H, Kawakami A, et al. Emergence of Epstein-Barr virus-
associated haemophagocytic syndrome upon treatment of systemic lupus eryth-
ematosus. Lupus 2006;15:51–3.
79. Kwon C, Jung Y, Yun D, et al. A case of acute pericarditis with hemophagocytic
syndrome, cytomegalovirus infection and systemic lupus erythematosus. Rheu-
matol Int 2008;28:271–3.
80. Lee S, Sugiyama M, Hishikawa T, et al. Thrombocytopenia in systemic lupus
erythematosus associated with cytomegalovirus infection. Scand J Rheumatol
1997;26:69.
81. Rouphael N, Talati N, Vaughan C, et al. Infections associated with haemophago-
cytic syndrome. Lancet Infect Dis 2007;7:814–22.
82. Sakamoto O, Ando M, Yoshimatsu S, et al. Systemic lupus erythematosus
complicated by cytomegalovirus-induced hemophagocytic syndrome and
colitis. Intern Med 2002;41:151–5.
90 Cuchacovich & Gedalia

83. Evans AS. E.B. virus antibody in systemic lupus erythematosus. Lancet 1971;1:
1023–4.
84. Pender MP. Infection of autoreactive B lymphocytes with EBV, causing chronic
autoimmune diseases. Trends Immunol 2003;24:584–8.
85. Niller HH, Wolf H, Minarovits J. Regulation and dysregulation of Epstein-Barr
virus latency: implications for the development of autoimmune diseases. Autoim-
munity 2008;41(4):298–328.
86. Lu JJ, Chen DY, Hsieh CW, et al. Association of Epstein-Barr virus infection with
systemic lupus erythematosus in Taiwan. Lupus 2007;16(3):168–75.
87. Harley JB, James JA. Epstein-Barr virus infection induces lupus autoimmunity.
Bull NYU Hosp Jt Dis 2006;64(1–2):45–50.
88. Harley JB, Harley IT, Guthridge JM, et al. The curiously suspicious: a role for
Epstein-Barr virus in lupus. Lupus 2006;15(11):768–77.
89. Gross AJ, Hochberg D, Rand WM, et al. EBV and systemic lupus erythematosus:
a new perspective. J Immunol 2005;174(11):6599–607.
90. Sundar K, Jacques S, Gottlieb P, et al. Expression of the Epstein-Barr virus
nuclear antigen-1 (EBNA-1) in the mouse can elicit the production of anti-dsDNA
and anti-Sm antibodies. J Autoimmun 2004;23:127–40.
91. Poole BD, Scofield RH, Harley JB, et al. Epstein-Barr virus and molecular
mimicry in systemic lupus erythematosus. Autoimmunity 2006;39:63–70.
92. Swanson-Mungerson M, Longnecker R. Epstein-Barr virus latent membrane
protein 2A and autoimmunity. Trends Immunol 2007;28:213–8.
93. Wang H, Nicholas MW, Conway KL, et al. EBV latent membrane protein 2A
induces autoreactive B cell activation and TLR hypersensitivity. J Immunol
2006;177:2793–802.
94. Finger E, Romaldini H, Lewi DS, et al. Ganciclovir-resistant, cytomegalic intersti-
tial lung disease in a patient with systemic lupus erythematosus. Clin Rheumatol
2007;26(10):1753–5.
95. Takei M, Yamakami K, Mitamura K, et al. A case of systemic lupus erythemato-
sus complicated by alveolar hemorrhage and cytomegalovirus colitis. Clin Rheu-
matol 2007;26(2):274–7.
96. Diaz F, Urkijo JC, Mendoza F, et al. Systemic lupus erythematosus associated
with acute cytomegalovirus infection. J Clin Rheumatol 2006;12(5):263–4.
97. Lee JJ, Teoh SC, Chua JL, et al. Occurrence and reactivation of cytomegalovirus
retinitis in systemic lupus erythematosus with normal CD4(1) counts. Eye 2006;
20(5):618–21.
98. Hrycek A, Kusmierz D, Mazurek U, et al. Human cytomegalovirus in patients with
systemic lupus erythematosus. Autoimmunity 2005;38(7):487–91.
99. Ikura Y, Matsuo T, Ogami M, et al. Cytomegalovirus associated pancreatitis in
a patient with systemic lupus erythematosus. J Rheumatol 2000;27:2715–7.
100. Kahl LE. Herpes-zoster infections in systemic lupus erythematosus: risk factors
and outcome. J Rheumatol 1994;21:84.
101. Moga I, Formiga F, Canet R, et al. Herpes-zoster virus infection in patients with
systemic lupus erythematosus. Rev Clin Esp 1995;195:530.
102. Hellman DB, Petri M, Whiting-O’Keefe Q. Fatal infections in systemic lupus
erythematosus: the role of opportunistic organisms. Medicine 1987;66:341–8.
103. Dhar JP, Kmak D, Bhan R, et al. Abnormal cervicovaginal cytology in women
with lupus: a retrospective cohort study. Gynecol Oncol 2001;82:4–6.
104. Tam LS, Chan AY, Chang AR, et al. Increased prevalence of squamous intrae-
pithelial lesions in systemic lupus erythematosus: association with papilloma
virus infection. Arthritis Rheum 2004;501(11):3619–25.
 Infections in SLE 91

105. Bernatsky S, Ramsey-Goldman R, Gordon C, et al. Factors associated with

abnormal Pap results in systemic lupus erythematosus. Rheumatology 2004;
43:1386–9.
106. Bateman H, Yazici Y, Leff L, et al. Increased cervical dysplasia in intravenous
cyclophosphamide-treated patients with SLE: a preliminary study. Lupus
2000;9:542–4.
107. Nath R, Mant C, Luxton J, et al. High risk of human papillomavirus type 16 infec-
tions and of development of cervical squamous intraepithelial lesions in
systemic lupus erythematosus patients. Arthritis Rheum 2007;57(4):619–25.
108. Sieving RR, Kauffman CA, Watanakukorn C. Deep fungal infection in systemic
lupus erythematosus. Three cases reported, literature reviewed. J Rheumatol
1975;2:61–72.
109. Choi SJ, Rho YH, Lee YH, et al. Disseminated candidiasis in systemic lupus
erythematosus. Clin Exp Rheumatol 2007;25(3):503.
110. Cassar CL. Nocardia sepsis in a multigravida with systemic lupus erythemato-
sus and autoimmune hepatitis. Anaesth Intensive Care 2007;35(4):601–4.
111. Justiniano M, Glorioso S, Dold S, et al. Nocardia brain abscesses in a male
patient with SLE: successful outcome despite delay in diagnosis. Clin Rheuma-
tol 2007;26(6):1020–2.
112. Kilincer C, Hamamcioglu MK, Simsek O, et al. Nocardial brain abscess: review
of clinical management. J Clin Neurosci 2006;13(4):481–5.
113. Cheng HM, Huang DF, Leu HB. Disseminated nocardiosis with initial manifesta-
tion mimicking disease flare-up of systemic lupus erythematosus in an SLE
patient. Am J Med 2005;118(11):1297–8.
114. Santen RJ, Wright IS. Systemic lupus erythematosus associated with pulmonary
nocardiosis. Arch Intern Med 1967;119:202–5.
115. Chen HS, Tsai WP, Leu HS, et al. Invasive fungal infection in systemic lupus
erythematosus: an analysis of 15 cases and a literature review. Rheumatology
2007;46(3):539–44.
116. Zumla A, Grange J. Infection and disease caused by environmental mycobac-
teria. Curr Opin Pulm Med 2002;8:166–72.
117. Hsu PY, Yang YH, Hsiao CH, et al. Mycobacterium kansasii infection presenting
as cellulitis in a patient with systemic lupus erythematosus. J Formos Med Assoc
2002;101:581–4.
118. Gordon MM, Wilson HE, Duthie FR, et al. When typical is atypical: mycobacterial
infection mimicking cutaneous vasculitis. Rheumatology 2002;41:685–90.
119. Laborde H, Rodrigue S, Cattoglio PM. Mycobacterium fortuitum in systemic
lupus erythematosus. Clin Exp Rheumatol 1989;7:291–3.
120. Mok MY, Wong SS, Chan TM, et al. Non-tuberculous mycobacterial infection in
patients with systemic lupus erythematosus. Rheumatology 2007;46(2):280–4.
121. Enzenauer RJ, McKoy J, Vincent D, et al. Disseminated cutaneous and synovial
Mycobacterium marinum infection in patient with systemic lupus erythematosus.
South Med J 1990;83:471–4.
122. Rutten MJ, van den Berg JC, van den Hoogen FH, et al. Nontuberculous myco-
bacterial bursitis and arthritis of the shoulder. Skeletal Radiol 1998;27:33–5.
123. Telgt DS, van den Hoogen FH, Meis JF, et al. Arthritis and spondylodiscitis
caused by Mycobacterium xenopi in a patient with systemic lupus erythemato-
sus. Br J Rheumatol 1996;35:1008–10.
124. Nakamura T, Yamamura Y, Tsuruta T, et al. Mycobacterium kansasii arthritis of
the foot in a patient with systemic lupus erythematosus. Intern Med 2001;40:
1045–9.
92 Cuchacovich & Gedalia

125. Hoffman GS, Myers RL, Stark FR, et al. Septic arthritis associated with Myco-
bacterium avium: a case report and literature review. J Rheumatol 1978;5:
199–209.
126. Zventina JR, Demos TC, Rubinstein H. Mycobacterium intracellulare infection of
the shoulder and spine in a patient with steroid-treated systemic lupus erythe-
matosus. Skeletal Radiol 1982;8:111–3.
127. Huang HC, Yu WL, Shieh CC, et al. Unusual mixed infection of thoracic
empyema caused by Mycobacteria tuberculosis, nontuberculosis mycobacteria
and Nocardia asteroides in a woman with systemic lupus erythematosus. J Infect
2007;54(1):e25–8.
128. Staples PJ, Gerding DN, Decker JL, et al. Incidence of infection in systemic
lupus erythematosus. Arthritis Rheumatology 1974;17:1–10.
129. Kang I, Park SH. Infectious complications in SLE after immunosuppressive ther-
apies. Curr Opin Rheumatol 2003;15:528–34.
130. Pillay VKG, Wilson DM, Ing TS, et al. Fungus infection in steroid-treated systemic
lupus erythematosus. JAMA 1968;205:261–5.
131. Rosner S, Ginzler EM, Diamond HS, et al. A multicenter study of outcome in
systemic lupus erythematosus. II. Causes of death. Arthritis Rheum 1982;25:
612–7.
132. Ashman RF, White RH, Wiesenhutter C, et al. Panhypogammaglobulinemia in
systemic lupus erythematosus: in vitro demonstration of multiple cellular
defects. J Allergy Clin Immunol 1982;70:465.
133. Swaak AJG, van den Brink HG. Common variable immunodeficiency in a patient
with systemic lupus erythematosus. Lupus 1996;5:242–6, I.K.
134. Tsokos GC, Smith PL, Balow JE. Development of hypogammaglobulinemia in
a patient with systemic lupus erythematosus. Am J Med 1986;81:1081–4.
135. Cronin ME, Balow JE, Tsokos GC. Immunoglobulin deficiency in patients with
systemic lupus erythematosus. Clin Exp Rheumatol 1989;7:359–64.
136. Stein A, Winkelstein A, Agarwal A. Concurrent systemic lupus erythematosus
and common variable hypogammaglobulinemia. Arthritis Rheum 1985;28:
462–5.
137. Baum CG, Chiorazzi N, Frankel S, et al. Conversion of systemic lupus erythema-
tosus to common variable hypogammaglobulinemia. Am J Med 1989;87:
449–56.
138. Sussman GL, Rivera VK, Kohler PF. Transition from systemic lupus erythemato-
sus to common variable hypogammaglobulinemia. Ann Intern Med 1983;99:
32–5.
139. Fernandez-Castro M, Mellor-Pita S, Jesus CM, et al. Common variable immuno-
deficiency in systemic lupus erythematosus. Semin Arthritis Rheum 2007;36:
238–45.
140. Rankin EC, Isenberg DA. IgA deficiency and SLE: prevalence in a clinic popu-
lation and a review of the literature. Lupus 2007;6:390–4.
141. Cassidy JT, Kitson RK, Selby CL. Selective IgA deficiency in children and adults
with systemic lupus erythematosus. Lupus 2007;16(8):647–50.
142. Slepian SA, Schwartz Weiss JJ, et al. Immunodeficiency with hyper IgM after
systemic lupus erythematosus. J Allergy Clin Immunol 1984;73:846–57.
143. Saiki O, Saeki Y, Tanaka T, et al. Development of selective IgM deficiency in
systemic lupus erythematosus patients with disease of long duration. Arthritis
Rheum 1987;30:1289–92.
144. Senaldi G, Ireland R, Bellingham AJ, et al. IgM reduction in systemic lupus
erythematosus. Arthritis Rheum 1988;31:1213.
 Infections in SLE 93

145. Takeuchi T, Nakagawa T, Maeda Y, et al. Functional defect of B lymphocytes in

a patient with selective IgM deficiency associated with systemic lupus erythe-
matosus. Autoimmunity 2001;34:115–22.
146. Goldstein MF, Goldstein AL, Dunsky EH, et al. Selective IgM immunodeficiency:
retrospective analysis of 36 adult patients with review of the literature. Ann
Allergy Asthma Immunol 2006;97:717–30.
147. Gluck T, Muller-Ladner U. Vaccination in patients with chronic rheumatic or auto-
immune diseases. Clin Infect Dis 2008;46(9):1459–65.
148. Holvast B, Huckriede A, Kallenberg CG, et al. Influenza vaccination in systemic
lupus erythematosus: safe and protective? Autoimmun Rev 2007;6:300–5.
149. Stojanovich L. Influenza vaccination of patients with systemic lupus erythemato-
sus (SLE) and rheumatoid arthritis (RA). Clin Dev Immunol 2006;13(2–4):373–5.
150. O’Neill SG, Isenberg DA. Immunizing patients with systemic lupus erythemato-
sus: a review of effectiveness and safety. Lupus 2006;15(11):778–83.