Clinical characteristics and prognosis of community-acquired pneumonia in autoimmune disease-induced immunocompromised host: A retrospective observational study

doi:10.5847/wjem.j.1920-8642.2020.03.003

Abstract

Abstract:

BACKGROUND: Community-acquired pneumonia (CAP) in autoimmune diseases (AID)-induced immunocompromised host (ICH) had a high incidence and poor prognosis. However, only a few studies had determined the clinical characteristics of these patients. Our study was to explore the characteristics and predictors of mortality in CAP patients accompanied with AID-induced ICH.

METHODS: From 2013 to 2018, a total of 94 CAP patients accompanied with AID-induced ICH, admitted to Emergency Department of Zhongshan Hospital, Fudan University, were enrolled in this study. Clinical data and the risk regression estimates of repeated predictors were evaluated by generalized estimating equations (GEEs) analysis. An open-cohort approach was used to classify patient’s outcomes into the survival or non-survival group.

RESULTS: The hospital mortality of patients with CAP occurring in AID-induced ICH was 60.64%. No significant differences were found with respect to clinical symptoms and lung images between survival and non-survival groups, while renal insufficiency and dysfunction of coagulation had higher proportions in non-survival patients (P<0.05). Both noninvasive ventilation (NIV) and invasive mechanical ventilation (IMV) were performed more frequently in non-survival group (P< 0.05). By the multivariate GEEs analysis, the repeated measured longitudinal indices of neutrophil-to-lymphocyte ratio (NLR) (odds ratio [OR]=1.055, 95% confidence interval [95%CI] 1.025-1.086), lactate dehydrogenase (LDH) (OR=1.004, 95%CI 1.002-1.006) and serum creatinine (sCr) (OR=1.018, 95%CI 1.008-1.028), were associated with a higher risk of mortality.

CONCLUSION: The CAP patients in AID-induced ICH had a high mortality. A significant relationship was demonstrated between the factors of NLR, LDH, sCr and mortality risk in these patients.

Key words: Community-acquired pneumonia, Immunocompromised hosts, Autoimmune disease, Prognostic marker

Zhong-shu Kuang, Yi-lin Yang, Wei Wei, Jian-li Wang, Xiang-yu Long, Ke-yong Li, Chao-yang Tong, Zhan Sun, Zhen-ju Song. Clinical characteristics and prognosis of community-acquired pneumonia in autoimmune disease-induced immunocompromised host: A retrospective observational study[J]. World Journal of Emergency Medicine, 2020, 11(3): 145-151.

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Underlying conditions	Number (%)
Total cases	94
IgA nephropathy	17 (18.09)
RA	16 (17.02)
SLE	8 (8.51)
Dermatomyositis	7 (7.45)
Membranous nephropathy	7 (7.45)
Membrano-proliferative glomerulonephritis	6 (6.38)
ANCA associated systemic vasculitis	5 (5.32)
ITP	5 (5.32)
Nephrotic syndrome	4 (4.26)
Pemphigoid	4 (4.26)
UCTD	3 (3.19)
Polymyositis	2 (2.13)
Sjogren’s syndrome	2 (2.13)
AS	2 (2.13)
Others	7 (7.45)

Variables	Number or median (%)
Total cases	94
Male	45 (47.90)
Death	57 (60.64)
Age (years)	57 (41-73)
Immunosuppressive therapy
Glucocorticoid and immunosuppressive agent	66 (70.21)
Glucocorticoid	25 (26.60)
Immunosuppressive agent	3 (3.19)
Comorbid illnesses
Chronic renal disease	33 (35.11)
Diabetes	14 (14.89)
Tobacco use	11 (11.70)
Chronic liver disease	3 (3.19)
Complications after infection
Respiratory failure	73 (77.66)
Cardiac dysfunction	30 (31.91)
Acute renal failure	26 (27.66)
Dysfunction of coagulation	18 (19.15)
Acute liver function impairment	14 (14.89)
Pneumothorax or subcutaneous emphysema	7 (7.45)
Clinical symptoms
Fever	80 (85.11)
Shortness of breath	72 (76.60)
Dry cough	66 (70.21)
Productive cough	50 (53.19)
Edema	11 (11.70)
Palpitate	9 (9.57)
Chest pain	6 (6.38)
Hemoptysis	4 (4.26)
Cyanosis	2 (2.13)
Causative pathogens (n=48)
Gram-negative bacteria	16 (33.33)
Gram-positive bacteria	14 (29.17)
Virus	7 (14.58)
Fungus	5 (10.42)
Atypical pathogen	3 (6.25)
Others	3 (6.25)
Features of lung image
Diffuse infiltration	85 (90.43)
Local infiltration	6 (6.38)
Pleural effusion	38 (40.43)
Oxygenation strategy
Noninvasive ventilation	49 (52.13)
Invasive mechanical ventilation	24 (25.53)
High-flow nasal cannula or O₂	21 (22.34)

Variables	Survival (n=37)	Non-survival (n=57)	P value
Male	18	31	0.674
Age (years)	56±15	57±16	0.664
Immunosuppressive therapy
Glucocorticoid and immunosuppressive agent	21	45
Glucocorticoid	13	12
Immunosuppressive agent	3	0
Comorbid illnesses
Diabetes	7	7	0.391
Chronic renal disease	12	21	0.825
Chronic liver disease	1	2	1.000
Tobacco use	7	4	0.104
PSI risk classes			0.026
II	15	10
III	10	12
IV	11	28
V	1	7
Complications after infection
Respiratory failure	26	47	0.196
Cardiac dysfunction	9	21	0.260
Hepatic insufficiency	3	11	0.235
Renal insufficiency	4	22	0.004
Dysfunction of coagulation	2	16	0.007
Pneumothorax or subcutaneous emphysema	1	6	0.239
Clinical symptoms
Fever	31	49	1.000
Dry cough	28	38	0.350
Productive cough	22	28	0.391
Hemoptysis	1	3	1.000
Chest pain	1	5	0.398
Cyanosis	0	2	0.518
Shortness of breath	26	46	0.446
Palpitate	4	5	0.733
Edema	6	5	0.329
Features of lung image
Local infiltration	3	3	0.675
Diffuse infiltration	32	53	0.426
Pleural effusion	15	23	1.000
Oxygenation strategy
Noninvasive ventilation	13	33	0.032
Invasive mechanical ventilation	4	17	0.042
High-flow nasal cannula or O₂	15	4	<0.001

Variables	OR	95% CI	P value
NLR	1.021	1.007-1.035	0.004
PaO₂/FiO₂	0.992	0.988-0.995	0.001
C-reactive protein	1.009	1.004-1.014	0.001
Albumin	0.899	0.857-0.944	0.001
Lactate dehydrogenase	1.003	1.002-1.005	0.001
D-dimer	1.064	1.021-1.110	0.003
Serum creatinine	1.007	1.002-1.012	0.004
Blood urea nitrogen	1.042	1.015-1.069	0.002
Uric acid	1.002	1.000-1.030	0.041

Variables	OR	95% CI	P value
Neutrophil to lymphocyte ratio	1.055	1.025-1.086	<0.001
Lactate dehydrogenase	1.004	1.002-1.006	0.001
Serum creatinine	1.018	1.008-1.028	<0.001