The causes and clinical significance of fever in systemic lupus erythematosus: a retrospective study of 487 hospitalised patients

Abstract

The causes of fever in systemic lupus erythematosus (SLE) are complicated. Differential diagnosis of fever in SLE is crucial for optimal management of these patients. To better understand the causes and characteristics of fever in SLE, the medical records of 1949 consecutive patients hospitalised for SLE from January 2002 to May 2007 were reviewed. A total of 487 SLE-hospitalised patients with fever were identified and retrospectively analysed. Among them, 265 patients had fever from infection, 206 had fever related to SLE, 8 had fever caused by both SLE activity and infections, 4 had fever caused by malignancies and 4 had fever ascribed to miscellaneous causes. The most common sites of infection were the respiratory tract (62.6%), urinary tract (8.6%), skin and mucosa (8.3%). A prednisone dose of ≤100 mg/d was able to suppress SLE fever in 80.6% of the patients, usually within 1–5 days. Compared to patients with infection fever, those with SLE fever were more likely to have lower serum complement C3 and a higher SLE Disease Activity Index score. Infection fever was found to be associated with the use of azathioprine within the last six months. In conclusion, infection and disease activity are the most common causes of fever in SLE. Those patients for whom SLE fever could not be suppressed by a higher dose of steroids usually had severe lupus encephalopathy or hemophagocytic syndrome.

Keywords

active fever infection steroid therapy systemic lupus erythematosus

Get full access to this article

View all access options for this article.

References

1 Dubois EL Tuffanelli DL . Clinical manifestations of systemic lupus erythematosus. Computer analysis of 520 cases. JAMA 1964; 190: 104–111.

2 Yang CD Wang XD Ye S . Clinical features, prognostic and risk factors of central nervous system infections in patients with systemic lupus erythematosus. Clin Rheumatol 2007; 26: 895–901.

3 Qian J Yang CD . Hemophagocytic syndrome as one of main manifestations in untreated systemic lupus erythematosus: two case reports and literature review. Clin Rheumatol 2007; 26: 807–810.

4 Stahl NI Klippel JH Decker JL . Fever in systemic lupus erythematosus. Am J Med 1979; 67: 935–940.

5 Hochberg MC . Updating the American college of rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum 1997; 40: 1725.

6 Ballestas HC . Postoperative fever: to what is the body really responding? AORN J 2007; 86: 983–988; quiz 989–992.

7 Bombardier C Gladman DD Urowitz MB . Derivation of the SLEDAI. A disease activity index for lupus patients. The committee on prognosis studies in SLE. Arthritis Rheum 1992; 35: 630–640.

8 Rovin BH Tang Y Sun J . Clinical significance of fever in the systemic lupus erythematosus patient receiving steroid therapy. Kidney Int 2005; 68: 747–759.

9 Zonana-Nacach A Camargo-Coronel A Yanez P . Infections in outpatients with systemic lupus erythematosus: a prospective study. Lupus 2001; 10: 505–510.

10.

10 Niederman MS Mandell LA Anzueto A . Guidelines for the management of adults with community-acquired pneumonia. Diagnosis, assessment of severity, antimicrobial therapy, and prevention. Am J Respir Crit Care Med 2001; 163: 1730–1754.

11.

11 Dellinger RP Levy MM Carlet JM . Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36: 296–327.

12.

12 Chaudhuri A Martinez-Martin P Kennedy PG . EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol 2008; 15: 649–659.

13.

13 Parker F . Examination of the skin and an approach to diagnosing skin diseases. In: JC Bennett F Plum , (ed), Cecil textbook of medicine. Philadelphia: Saunders; 1996. p. 2190–2193.

14.

14 Cervera R Khamashta MA Font J . Morbidity and mortality in systemic lupus erythematosus during a 10-year period: a comparison of early and late manifestations in a cohort of 1,000 patients. Medicine (Baltimore) 2003; 82: 299–308.

15.

15 Jallouli M Frigui M Marzouk S . Infectious complications in systemic lupus erythematosus: a series of 146 patients. Rev Med Interne 2008; 29: 626–631.

16.

16 Inoue T Takeda T Koda S . Differential diagnosis of fever in systemic lupus erythematosus using discriminant analysis. Rheumatol Int 1986; 6: 69–77.

17.

17 Bach JF . Infections and autoimmune diseases. J Autoimmun 2005; 25(Suppl.): 74–80.

18.

18 Bosch X Guilabert A Pallares L . Infections in systemic lupus erythematosus: a prospective and controlled study of 110 patients. Lupus 2006; 15: 584–589.

19.

19 Massardo L Martinez ME Baro M . Infections in systemic lupus erythematosus. Rev Med Chil 1991; 119: 1115–1122.

20.

20 Oh HM Chng HH Boey ML . Infections in systemic lupus erythematosus. Singapore Med J 1993; 34: 406–408.

21.

21 Shyam C Malaviya AN . Infection-related morbidity in systemic lupus erythematosus: a clinico-epidemiological study from northern India. Rheumatol Int 1996; 16: 1–3.

22.

22 Gladman DD Hussain F Ibanez D . The nature and outcome of infection in systemic lupus erythematosus. Lupus 2002; 11: 234–239.

23.

23 Mok CC Lau CS . Lupus in Hong Kong Chinese. Lupus 2003; 12: 717–722.

24.

24 Al-Rayes H Al-Swailem R Arfin M . Systemic lupus erythematosus and infections: a retrospective study in Saudis. Lupus 2007; 16: 755–763.

25.

25 Kang I Park SH . Infectious complications in SLE after immunosuppressive therapies. Curr Opin Rheumatol 2003; 15: 528–534.

26.

26 Mok MY Lo Y Chan TM . Tuberculosis in systemic lupus erythematosus in an endemic area and the role of isoniazid prophylaxis during corticosteroid therapy. J Rheumatol 2005; 32: 609–615.

27.

27 Tam LS Li EK Wong SM . Risk factors and clinical features for tuberculosis among patients with systemic lupus erythematosus in Hong Kong. Scand J Rheumatol 2002; 31: 296–300.

28.

28 Balakrishnan C Mangat G Mittal G . Tuberculosis in patients with systemic lupus erythematosus. J Assoc Physicians India 1998; 46: 682–683.

29.

29 Feng PH Tan TH . Tuberculosis in patients with systemic lupus erythematosus. Ann Rheum Dis 1982; 41: 11–14.

30.

30 Victorio-Navarra ST Dy EE Arroyo CG . Tuberculosis among Filipino patients with systemic lupus erythematosus. Semin Arthritis Rheum 1996; 26: 628–634.

31.

31 Pryor BD Bologna SG Kahl LE . Risk factors for serious infection during treatment with cyclophosphamide and high-dose corticosteroids for systemic lupus erythematosus. Arthritis Rheum 1996; 39: 1475–1482.

32.

32 Noel V Lortholary O Casassus P . Risk factors and prognostic influence of infection in a single cohort of 87 adults with systemic lupus erythematosus. Ann Rheum Dis 2001; 60: 1141–1144.