title: Invasive fungal infection in systemic lupus erythematosus: an analysis of 15 cases and a literature review.
abstract: OBJECTIVE
  To analyse 15 cases of invasive fungal infection and mortality parameters in the largest series in the last 35 yrs of patients with systemic lupus erythematosus (SLE) at a single medical centre.
  
  
  METHODS
  Fifteen patients with SLE and invasive fungal infections were retrospectively enrolled. Clinical and laboratory data, fungal species and infected sites, corticosteroid and immunosuppressant doses and SLE disease activity index were assessed retrospectively. Comparison and correlation analyses utilized Fisher's exact test, the chi-square test, Mann-Whitney U-test or the Wilcoxon signed-rank test where appropriate.
  
  
  RESULTS
  In contrast to other review reports, Cryptococcus neoformans was the most commonly identified fungus in this Taiwanese series. Notably, the prevalence of autoimmune haemolytic anaemia and positive results for the anti-cardiolipin antibody in this study were significantly higher than those in SLE patients in general (P < 0.0001 and P < 0.0001, respectively). Fungal infection contributed to cause of death in 7 of 15 (46.7%) patients, of which Cryptococcus neoformans accounted for six of these infections. Low-dose prednisolone (<1 or <0.5 mg/kg/day based on arbitrary division) prior to fungal infection tended to correlate with 1 yr mortality after diagnosis of SLE (P = 0.077 or P = 0.080). However, following fungal infection, patients who died from infection itself had been prescribed with higher prednisolone dose or equivalent than surviving patients (P = 0.016). All SLE patients with fungal infections had active SLE (SLEDAI >7).
  
  
  CONCLUSIONS
  Cryptococcus neoformans infection accounted for most fatalities in SLE patients with fungal infections in this series. Active lupus disease is probably a risk factor for fungal infection in SLE patients. Notably, low prednisolone doses prior to fungal infection or high prednisolone doses following fungal infection tended to associate with or correlated to fatality, respectively. Therefore, we suggest that different prednisolone doses prescribed at various times impact the incidence of fungal infection and its associated mortality.
authors.affiliation: Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kwei-san Hsiang, Tao-Yuan, Taiwan.
authors.forename: H S
authors.initials: HS
authors.lastname: Chen
authors.forename: W P
authors.initials: WP
authors.lastname: Tsai
authors.forename: H S
authors.initials: HS
authors.lastname: Leu
authors.forename: H H
authors.initials: HH
authors.lastname: Ho
authors.forename: L B
authors.initials: LB
authors.lastname: Liou
mesh_terms: D000328:Adult; D003453:Cryptococcosis / Q000150:complications; D003455:Cryptococcus neoformans; D004334:Drug Administration Schedule; D004812:Epidemiologic Methods; D005260:Female; D005938:Glucocorticoids / Q000008:administration & dosage / Q000009:adverse effects; D006801:Humans; D008180:Lupus Erythematosus, Systemic / Q000150:complications* / Q000188:drug therapy; D008297:Male; D008875:Middle Aged; D009181:Mycoses / Q000150:complications*; D009894:Opportunistic Infections / Q000150:complications*; D011239:Prednisolone / Q000008:administration & dosage / Q000009:adverse effects; D012720:Severity of Illness Index
chemical_list: D005938:Glucocorticoids; D011239:Prednisolone