Lupus And Infections And Immunizations

Daniel J. Wallace, M.D.
Clinical Chief of Rheumatology, Cedars Sinai Medical Center
Associate Clinical Professor of Medicine
University of California at Los Angeles, Los Angeles, CA

Allan L. Metzger
Attending Physician, Cedars Sinai Medical Center
Clinical Professor of Medicine
University of California at Los Angeles, Los Angeles, CA

Better techniques for diagnosis, evaluation and disease management combined with more judicious use of medications have significantly improved the prognosis for lupus patients over the past two decades. Thirty five years ago, only 40 percent of the people living with lupus were expected to live more than three years following diagnosis. With early diagnosis and current methods of therapy, 80-90 percent of lupus patients now live for more than 10 years after their diagnosis and many can look forward to a normal lifespan.

Prior to the medical advances made in lupus diagnosis and treatment, most patient deaths were the result of renal failure or central nervous system involvement. Today, as many patients with lupus will die from infection as from active systemic disease. This is an important reason for developing an increased awareness about lupus and its relationship to infections and immunizations. Lupus patients are more susceptible to infection than most people for two reasons:

1. Lupus directly affects a person's immune system, reducing his or her ability to prevent and fight infection.
2. Many of the drugs used to treat lupus suppress the function of the immune system, leaving the patient more prone to infection.

DIRECT EFFECTS OF LUPUS ON THE IMMUNE SYSTEM

Lupus patients have abnormalities in their immune systems that predispose them to develop infections.

EFFECTS OF MEDICATIONS USED IN THE TREATMENT OF LUPUS

Cortisone-like drugs (Prednisone) and cytotoxic drugs such as azathioprine (Imuran) and cyclophosphamide (Cytoxan) increase a person's susceptibility to infections because they suppress both normal and abnormal immune function. However, the control of lupus activity is usually more important than the danger posed by a possible infection due to the use of immunosuppressive medications. The risk of infection parallels the dose and the duration of treatment with steroids. A daily dose of 20 mg. of Prednisone is enough to impose a significant risk. Administration of steroids every other day ("alternate day" treatment) decreases the risk and incidence of infections.

Lupus patients are more susceptible to infection even if they do not take corticosteroids. Lupus experts such as Dr. Marian Ropes sparingly used steroids in treating her patients in the 1940s and 1950s. Yet, Dr. Ropes published data showing that the majority of her patients developed serious infections during their disease course - even on low dose steroids.

TYPES OF INFECTION IN SLE

Infections that occur in people with lupus fall into two categories. The first category includes infections caused by organisms which can induce infection in persons with lupus and in the general population as well. This category includes organisms such as streptococcus (which causes strep throat) and staphylococcus (which causes staph infections).

The second category consists of "opportunistic" infections. Opportunistic infections are caused by organisms capable of inducing disease only when one's immune system is weakened. Most of the opportunistic infections are fungal, parasitic or protozoan. The most common infections that lupus patients contract involve the respiratory tract, skin and urinary tract and do not usually require hospitalization. Fortunately, only a few lupus patients will need aggressive hospital treatment for infections. However, infections in lupus patients tend to last longer and require a longer course of treatment with antibiotics than infections in people who do not have lupus. Lupus patients are at an unusually high risk for contracting salmonella, herpes zoster and candida (yeast) infections.

CLINICAL EVALUATION OF POSSIBLE INFECTION

Active lupus and infection may share many symptoms. Further, infection can induce a lupus flare or be difficult to distinguish from a lupus flare. For example, fever and decreased energy are nonspecific symptoms that may be associated with both lupus flares or infections. More specific symptoms, like sore throat or pain on taking a deep breath, may also occur with either a flare of lupus or with infection. Therefore, it is important for a person with lupus to contact his or her physician whenever symptoms are suggestive of either a disease flare or an infection, so that a medical history and physical examination can be performed.

Laboratory tests including white blood cell counts may help a physician to distinguish an infection from a lupus flare. A low white blood cell count usually suggests active lupus (although certain viruses can also give a low white count) while a high count suggests infection. The physician may also wish to get a throat, urine, blood or stool culture and a complete blood count (CBC) or chest X-ray. Some physicians find a C-reactive protein (CRP) blood test to be helpful in differentiating active lupus from infection, but this is controversial. Fevers may be due to an infection, a drug reaction or active lupus.

Any lupus patient with a fever should be thoroughly evaluated, especially if the patient is also taking aspirin, nonsteroidal medications (e.g., Advil, Naprosyn) or steroids which lower body temperature.

If necessary, patients with suspected life-threatening infections of unknown source may need to be hospitalized. Here, the patient may be observed, cultures taken and tests such as gallium scanning, bone marrow biopsy, lymph node biopsy or bronchoscopy can be performed to help make a rapid diagnosis.

TREATMENT AND PREVENTION OF INFECTION

The treatment of infections in lupus patients is basically the same as for other patients. Even those taking high doses of immunosuppressive medications for their lupus may respond well to antibiotics. The use of sulfa drugs in the treatment of infections should be avoided whenever possible, because they can increase photosensitivity. To prevent possible infections, patients at high risk of infection often benefit from taking antibiotics before dental treatment or surgical procedures. In general, individuals with lupus should avoid exposure to people with colds or other infections.

PREVENTION OF INFECTION: IMMUNIZATION

The risk of certain types of infection can be decreased with immunization (vaccinations). Nearly all individuals with lupus have been vaccinated against a variety of diseases with little difficulty. However, it is possible that immunization with vaccines that use live viruses will result in a lupus flare. Nevertheless, polio, measles and tetanus vaccines, which all use live viruses, have been given to hundreds of thousands of lupus patients with no adverse reactions. Passive immunization (i.e., vaccinating the patient with a killed virus), poses no problems in lupus patients. Gammaglobulin is an example of a vaccine which uses a nonspecific antibody instead of a live virus.

It should be noted that lupus patients may have adverse reactions to two types of immunizations. First, some lupus patients who receive allergy shots (immunotherapy) will experience a lupus flare following this treatment. For this reason, in 1989, the World Health Organization recommended that patients with autoimmune diseases should not receive certain types of allergy shots. Allergy shots (immunotherapy) might cause the patient to make more anti-DNA and other lupus-related antibodies in addition to making antibodies against the agent causing the allergy. Lupus patients are advised to consult their rheumatologist before receiving any type of allergy immunotherapy.

Some lupus patients may also experience difficulties after receiving tetanus or flu vaccines. It seems that flu vaccines do not work as well if the patient has lupus; antibody levels against the flu virus achieve only half the desired level for half as long in those with lupus. Additionally, up to 20% of patients with lupus may feel sick or achy for a few days following a flu vaccination. This is twice as many people as in the general population, where only 10% of individuals will suffer such adverse effects following a flu shot. Because of these potential problems, lupus patients should consult their physician before receiving any vaccine.

lupus@piper.hamline.edu
Last modified: 1996-07-30