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Lupus and Infections

Infections are a significant cause of concern for those with lupus, accounting for up to 30% of all lupus deaths!  So, what are the risks, and what can be done to lower them?


Introduction to Lupus and Infections  

Infections and autoimmunity have a complex relationship.  The immune system must be constantly ready to fight a possible invasion from a bewildering number of pathogens, and yet, not over-react in a way that can damage a person’s own tissues and organs.  This is a tricky balance in healthy individuals, it is particularly challenging for those with lupus.

Unfortunately, infections are all too common for those living with systemic lupus erythematosus.  There are several reasons for this. Some with SLE have a genetic predisposition to infections, and many lupus medications weaken the immune system and may leave it more open to infections.

Here are some of the quick facts:

  • A compromised immune system means that those with lupus can have an increased risk for infections.
  • Yet, the kinds of infections are about the same as those in the general population – in particular, infections of the lungs, skin and urinary tract.
  • Invasive bacterial infections are more common and often more severe in lupus patients.
  • One of the tricky aspects of infections with lupus is the difficulty in determining whether inflammatory symptoms are due to an actual infection or from a lupus flare.
  • Some kinds of infections are known to increase the risk of triggering lupus.

While not all infections can be prevented, there are steps to decrease the risk of severe illness. So, understanding individual risk, knowing the signs, and reporting health changes right away can help stave off or minimize serious infection complications for those with lupus.


Who are at the greatest risk of infection?

Those with lupus nephritis (LN) bear the most significant risk for bacterial infections. African and Native American female children with LN who have other serious health conditions and take corticosteroids are at exceptionally high risk. One study found that those with LN have a 10x more significant risk of developing bacterial infections than those without LN and have a 2x more substantial chance of hospitalization. However, the risk for infection seems lower for those with LN who take the anti-malarial hydroxychloroquine (Plaquenil).

Other infection risk factors for those with lupus include:

  • Taking prednisone or taking specific dosages – studies have shown those with major infections take on average 7.5mg/day;
  • Combinations of some immunosuppressants, such as mycophenolate mofetil, azathioprine, and cyclophosphamide with glucocorticoids;
  • Being African American, Native American/Alaska Native, or Hispanic ethnicities;
  • Social determinants, such as having low socioeconomic status;
  • Genetic factors, like complement deficiencies, mannose-binding lectin, and others that can afflict lupus patients’
  • Age, especially between 51-64 years, and
  • Being male with lupus.


Which infections pose the greatest risks?

Most infections that affect those living with lupus are bacterial.  One study found that 96% of the infections among participants were bacterial, especially those affecting the skin, respiratory system, and urinary tract.  The most common infections were pneumonia (lungs), cellulitis (a skin infection that often develops on the legs), and bacteremia (bacteria found in blood and often referred to as blood poisoning, sepsis, or septicemia).

Bacteremia caused by the bacteria, E. coli, can result in urinary tract infections (UTIs).  In fact, about 36% of those with lupus experience UTIs, more so than the general population.

Viral infections are also common and include influenza and herpes zoster (shingles). One study found that shingles accounted for approximately 40% of hospitalizations from infection for those with lupus. Less common are fungal infections, including aspergillosis, which is a fungal infection of the lungs caused by mold, pneumocystis, a lung infection often found in those with AIDS or who have undergone chemotherapy, and cryptococcosis that occurs by inhaling an environmental fungus that is usually harmless to healthy people, but can be deadly for those with compromised immune systems.


Can infections cause lupus? 

Not only does having lupus increase the risk for infection, but some infections may increase the risk of getting lupus.

The types of pathogens that may lead to lupus include:

  • Epstein-Barr virus (EBV), which can turn into mononucleosis. Surprisingly, up to 95% of the general population and 99.5% of those with lupus have EBV, even though many never experience symptoms.
  • Parvovirus B19, which causes a face rash in children called “slapped-cheek disease;”
  • Human endogenous retroviruses, or “fossil viruses” that have been inherited throughout human evolution and are similar to today’s viruses, such as human immunodeficiency virus (HIV) and leukemia;
  • Herpes zoster virus, which causes chickenpox and shingles; and
  • Cytomegalovirus, a member of the herpes virus family that many unknowingly carry yet remain healthy. This theory is somewhat controversial, though higher cytomegalovirus strains are often found in those with lupus than in the healthy population.

Leaky Gut Infections:  There is growing evidence that a leaky gut in lupus patients may allow bacteria to enter and infect the blood stream and cause inflammation and initiate the autoimmune response.

The Hygiene Hypothesis:  Surprisingly, a lack of infection may also increase the risk for lupus. The hygiene hypothesis, which was first proposed in the 1980’s, attempts to explain the research data that shows that as most infections have declined in Western countries, the rates of autoimmunity and allergies have increased. The reasons are still unclear, but the assumption is that a certain amount of exposure to some pathogens (especially when young) can be beneficial to a balanced immune system.


How can infections be prevented?

While infections may still occur from time to time, some measures can be taken to decrease the risk of severe infection, such as:

  • Achieving and maintaining low lupus disease activity;
  • Completing recommended health screenings;
  • Getting vaccinations when advised by a trusted healthcare practitioner;
  • Maintaining good hygiene habits;
  • Treating cuts and scrapes immediately;
  • Keeping a clean and tidy home;
  • Staying away from the those with infectiouns;
  • Remaining hydrated;
  • Eating a nutritious diet and maintaining a healthy weight and microbiome;
  • Monitoring body temperature regularly and reporting any signs of fever immediately; and
  • Taking care of mental health.

Stay vigilant!  Sometimes, it can be hard to tell if it is an infection or lupus flare since both can cause inflammation, aches, pains, and fever. Regardless, it is crucial to see a practitioner right away because an infection needs to be treated entirely differently than a flare. For example, an infection requires antimicrobial treatment, while a flare requires immunosuppressive therapy. In addition, it may be hard for a practitioner to determine if the fever is from infection or flare, especially if there are no other symptoms. In this case, the practitioner may check to see if C-reactive protein levels are exceptionally high, an indicator of actual infection.


In Conclusion

Infections are a part of life for everyone, but they are a significant health risk for those living with lupus.  The reasons for this include genetics, immunosuppressant medications and social determinants of health – among others.  Also, infections have been linked to the initiation of lupus and to lupus flares.  Anyone who is immunocompromised should be vigilant in not only looking for infections, but also trying to prevent them as much as possible.  Report any changes in health or symptoms, take all sensible precautions and maintain your prescribed lupus treatments.  That way, not only can infections be limited, but your immune system will have fewer reasons to become over-active!

 

References

 

Battaglia, M., & Garrett-Sinha, L. A. (2021). Bacterial infections in lupus: Roles in promoting immune activation and in pathogenesis of the disease.Journal of Translational Autoimmunity, 4, https://doi.org/10.1016/j.jtauto.2020.100078

Feldman, C., Hiraki. L., Winkelmayer. W., Marty, F., Franklin, J., Kim, S., & Costenbader, K. (2015). Serious infections among adult Medicaid beneficiaries with systemic lupus erythematosus and lupus nephritis. Arthritis & Rheumatology, 67(6), 1577-1585. https://doi.org/10.1002/art.39070

Sandman-Goddard, G., & Shoenfeld, Y. (2003). SLE and infections. Clinical Reviews in Allergy & Immunology, 25(1), 29-40  doi: 10.1385/CRIAI:25:1:29

Hiraki. L., Feldman, C., Marty, F., Winkelmayer, W., Guan, H., & Costenbader, K. (2017). Serious infection rates among children with systemic lupus erythematosus enrolled in Medicaid. Arthritis Care & Research, 69(11), 1620-1626. https://dx.doi.org/10.1002%2Facr.23219

Jung, J. & Suh, C. (2017). Infection in systemic lupus erythematosus, similarities, and differences with lupus flare. Korean Journal of Internal Medicine, 32(3), 429-438. https://dx.doi.org/10.3904%2Fkjim.2016.234

Okada, H., Kuhn, C., Feillet, H., & Bach, J. (2010). The ‘hygiene hypothesis’ for autoimmune and allergic diseases: an update. Clinical & Experimental Immunology, 160(1), 1-9. https://doi.org/10.1111/j.1365-2249.2010.04139.x

Ruiz-Irastorza, G., Olivares, N., Ruiz-Arruza, I., Martinez-Berriotxoa, A., Egurbide, M., & Aguirre, C. (2009). Predictors of major infections in systemic lupus erythematosus. Arthritis Research & Therapy, 11, article R109. https://doi.org/10.1186/ar2764

Tektonidou, M., Wang, Z., Dasgupta, A., & Ward, M. (2015). Burden of serious infections in adults with systemic lupus erythematosus: a national population-based study, 1996-2011. Arthritis Care & Research, 67(8), 1078-1085. https://doi.org/10.1002/acr.22575

 

Author: Liz Heintz

Liz Heintz is a technical and creative writer who received her BA in Communications, Advocacy, and Relational Communications from Marylhurst University in Lake Oswego, Oregon. She most recently worked for several years in the healthcare industry. A native of San Francisco, California, Liz now calls the beautiful Pacific Northwest home.

All images, unless otherwise noted, are property of and were created by Kaleidoscope Fighting Lupus. To use one of these images, please contact us at [email protected] for written permission; image credit and link-back must be given to Kaleidoscope Fighting Lupus.

All resources provided by us are for informational purposes only and should be used as a guide or for supplemental information, not to replace the advice of a medical professional. The personal views expressed here do not necessarily encompass the views of the organization, but the information has been vetted as a relevant resource. We encourage you to be your strongest advocate and always contact your healthcare practitioner with any specific questions or concerns.

 

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