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Infection in systemic lupus erythematosus-associated diffuse alveolar hemorrhage: a potential key to improve outcomes

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Abstract

Objectives

This study aimed to investigate the clinical characteristics, outcomes, and associated factors of patients with systemic lupus erythematosus-associated diffusive alveolar hemorrhage (SLE-DAH) stratified by infection status in a national representative cohort.

Methods

This single-center retrospective study included 124 consecutive patients with SLE-DAH in a tertiary care center between 2006 and 2021. The diagnosis of DAH was made based on a comprehensive evaluation of clinical manifestations, laboratory and radiologic findings, and bronchoalveolar lavage. Demographics, clinical features, and survival curves were compared between patients with bacterial, non-bacterial, and non-infection groups. Univariate and multivariate logistic regression analyses were performed to determine the factors independently associated with bacterial infection in SLE-DAH.

Results

Fifty-eight patients with SLE-DAH developed bacterial infection after DAH occurrence, thirty-two patients developed fungal and/or viral infection, and thirty-four patients were categorized as non-infection. The bacterial infection group have a worse prognosis (OR 3.059, 95%CI 1.469–6.369, p = 0.002) compared with the other two groups, with a mortality rate of 60.3% within 180 days after DAH occurrence. Factors independently associated with bacterial infections in SLE-DAH included hematuria (OR 4.523, 95%CI 1.068–19.155, p = 0.040), hemoglobin drop in the first 24 h after DAH occurred (OR 1.056, 95%CI 1.001–1.115, p = 0.049), and anti-Smith antibody (OR 0.167, 95%CI 0.052–0.535, p = 0.003). Glucocorticoid pulse therapy and cyclophosphamide were administered in more than 50% of patients regardless of their infectious status. According to clinical experience at our hospital and in previous studies, we recommended a comprehensive management algorithm for SLE-DAH based on infection stratification.

Conclusion

Infection, especially bacterial infection, is a severe complication and prognostic factor of SLE-DAH. Comprehensive management strategies, including diagnosis, evaluation, treatment, and monitoring, based on infection stratification may fundamentally improve outcomes of patients with SLE-DAH.

Key Points

• Bacterial infection is an important, but neglected, prognosis factor of systemic lupus erythematosus (SLE)-associated diffusive alveolar hemorrhage (DAH).

• Hematuria, hemoglobin drop, and anti-Smith antibody can independently predict bacterial infections in SLE-DAH.

• We put forward a comprehensive management algorithm based on infection stratification for SLE-DAH.

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Data Availability

The data underlying this article are available in the article.

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Funding

This work was supported by the Chinese National Key Technology R&D Program, Ministry of Science and Technology (2021YFC2501301-5, 2017YFC0907601-3), Beijing Municipal Science & Technology Commission (No.Z201100005520022, 23, 25–27), and CAMS Innovation Fund for Medical Sciences (CIFMS) (2021-I2M-1–005).

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Authors and Affiliations

  1. Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China

    Mucong Li, Wei Bai, Shangzhu Zhang, Jiuliang Zhao, Chanyuan Wu, Mengtao Li, Xinping Tian & Xiaofeng Zeng

  2. Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking, Union Medical College, Beijing, 100730, China

    Yanhong Wang

  3. Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China

    Lan Song

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  1. Mucong Li
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Contributions

MCL collected the data, performed formal analyses, and drafted the original manuscript. WB, SZZ, and JLZ collected the cases. YHW supervised all data analyses. LS evaluated all pulmonary imaging of the cases. CYW designed the study and revised the manuscript. MTL, XPT, and XFZ reviewed the manuscript. All the authors reviewed and approved the final version of the manuscript.

Corresponding author

Correspondence to Chanyuan Wu.

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Li, M., Bai, W., Wang, Y. et al. Infection in systemic lupus erythematosus-associated diffuse alveolar hemorrhage: a potential key to improve outcomes. Clin Rheumatol 42, 1573–1584 (2023). https://doi.org/10.1007/s10067-023-06517-8

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