Is initial C-reactive protein level associated with corticosteroid use in lupus erythematosus patients during a bacterial infection episode?

doi:10.1016/j.imlet.2017.03.008

Immunology Letters

Volume 185, May 2017, Pages 84-89

https://doi.org/10.1016/j.imlet.2017.03.008 Get rights and content

Highlights

•
CRP level is not suppressed by corticosteroid or immunosuppressant in SLE patients.
•
CRP level reflects bacterial infection under SLE background.
•
CRP level is a good indicator for bacterial infection in SLE patients.

Abstract

Objective

C-reactive protein (CRP), a marker for inflammation, indicates bacterial infection in systemic lupus erythematosus (SLE) when markedly elevated. Our study investigated the association of regular corticosteroid or immunosuppressant use with initial CRP level in febrile SLE patients with bacterial infection.

Methods

This retrospective cohort study included adult SLE patients (18 years of age or older) who presented with fever at the emergency department from January 2008 to December 2012. Data were retrieved from our institutional database.

Results

CRP levels in the total 193 patient database were significantly increased in the bacterial infection group compared to the no infection and non-bacterial infection groups. Seventy-eight (86.7%) of the 90 patients in the bacterial infection group took regular corticosteroids (mean equivalent dose of prednisolone 0.33 ± 0.26 mg/kg/day) and 55 (61.1%) used immunosuppressants. Mean CRP level in the bacterial infection group was 97.8 mg/L. CRP level was lower in patients using corticosteroids, but the difference between users and nonusers of corticosteroids was not statistically significant (p = 0.367). The difference in CRP level between immunosuppressant and non-immunosuppressant users was also not significant (p = 0.599). The Spearman test found no correlation between corticosteroid dosage and CRP level (p = 0.911).

Conclusion

Initial CRP level was not significantly associated with regular corticosteroid or immunosuppressant use in SLEs patients during a bacterial infection episode, and CRP level was not dose-dependently related to daily corticosteroid use. An elevated CRP level might be an appropriate marker for bacterial infection at the emergency department for febrile SLE patients.

Introduction

Fever is a common presentation at emergency departments (EDs) in patients with systemic lupus erythematosus (SLE) [1], [2]. The differential diagnosis of fever in lupus patients is broad and includes lupus flare, and bacterial, viral, or fungal infection. Lupus flare results in tissue damage and inflammation, i.e., symptoms and signs that are similar to those of infections [3], [4]. The fever pattern is not helpful for diagnosis, especially because the course of this disease is unpredictable and its stage uncertain. In addition, most patients are taking immunosuppressants or corticosteroids regularly, drugs that can mask the clinical findings and delay the diagnosis. But it t is important for emergency physicians to be able to identify bacterial infection in order to start antibiotic treatment promptly [5], [6], [7].

Certain laboratory parameters can distinguish infection from disease flare in SLE [8]. C-reactive protein (CRP) is a marker of inflammatory and infectious processes [9]. But in contrast to the elevations of CRP level seen in other inflammatory diseases, such as rheumatoid arthritis and ankylosing spondylitis, the elevation of CRP during lupus flare is modest [10], [11], and therefore marked elevation of CRP level in a febrile lupus patient indicates a bacterial infection [12], [13], [14].

However, several studies have demonstrated the association of corticosteroid and immunosuppressant use with lower CRP levels [15], [16], [17], [18], and this association might interfere with the use of CRP as a diagnostic tool in SLE. Whether there is an association of CRP level with the regular use of corticosteroids and immunosuppressants and whether a dose-response relationship exists between corticosteroid use and CRP level in lupus patients with bacterial infection are major concerns. Therefore, this study investigated CRP levels at initial presentation in the emergency department (ED) of febrile SLE patients with no infection, non-bacterial infections, and bacterial infections, and the association between regular corticosteroid or immunosuppressant use and initial CRP level in the ED in the group with bacterial infection.

Section snippets

Study design and patient selection

This retrospective cohort study was conducted at a university-affiliated teaching hospital averaging approximately 130,000 visits annually. The Hospital Ethics Committee on Human Research reviewed and approved the study protocol and exempted the study from the need for informed consent.

The study cohort was adult lupus patients (18 years of age or older) admitted to our hospital through the ED because of fever, during the period from January 2008 to December 2012. Fever was defined as a tympanic

Results

Of the 383 patients enrolled in this study, data from 190 patients were excluded because of no data on corticosteroid use, incomplete records, or no data on the CRP level; 193 patients were then included for analysis. (Fig. 1)

Patients’ characteristics are shown in Table 1. The three groups of patients (no infection, non-bacterial infection, bacterial infection) were similar in gender, blood pressure, corticosteroid use and immunosuppressant use. However, patients with bacterial infection were

Discussion

Corticosteroids are commonly used to treat lupus-related inflammation[22], and corticosteroids have been reported to decrease CRP levels in a number of illnesses [15], [16], [17], [23], [24]. Our study demonstrated no significant association between chronic steroid use and CRP level at entry into the ED at the beginning of an episode of bacterial infection. In addition, no dose-response relationship between corticosteroid dose and initial CRP level was seen in lupus patients entering the ED for

Conclusion

Initial CRP level was not significantly associated with the regular corticosteroid or immunosuppressant use in febrile lupus patients during an infection episode, and CRP level was not dose-dependently related to corticosteroid use. An elevated CRP level might by an appropriate index for bacterial infection at emergency department in such population.

Declaration of interest

None of the authors report any competing interests including financial and personal relationships with the other people or organizations mentioned in the article.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgements

None.

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¹: Kuo-Cheng Wang and Peng-Huei Liu contribute to the article equal as first author.

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Is initial C-reactive protein level associated with corticosteroid use in lupus erythematosus patients during a bacterial infection episode?

Highlights

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Study design and patient selection

Results

Discussion

Conclusion

Declaration of interest

Funding

Acknowledgements

Clinical manifestations of systemic erythematosus. Computer analysis of 520 cases

JAMA

Fever in systemic lupus erythematosus

Am. J. Med.

Viruses and lupus: the viral hypothesis

Lupus

Acute viral infections in patients with systemic lupus erythematosus: description of 23 cases and review of the literature

Medicine (Baltimore).

The course of systemic lupus erythematosus

J. Chronic Dis.

Infections in compromised host

Q. J. Med.

Fatal infections in systemic lupus erythematosus: the role of opportunistic organisms

Medicine (Baltimore).

Systemic lupus erythematosus and infections: clinical importance of conventional and upcoming biomarkers

Autoimmun. Rev.

C-reactive protein: a critical update

J. Clin. Invest.

C-reactive protein in systemic lupus erythematosus

Arthritis Rheum.

Value of serum C-reactive protein measurement in the investigation of fever in systemic lupus erythematosus

Ann. Rheum. Dis.

C-reactive protein levels during disease exacerbations and infections in systemic lupus erythematosus: a prospective longitudinal study

J. Rheumatol.

C-reactive protein in the differential diagnosis between infection and disease reactivation in SLE

J. Rheumatol.

C-reactive protein is a more sensitive and specific marker for diagnosing bacterial infections in systemic lupus erythematosus compared to S100A8/A9 and procalcitonin

J. Rheumatol.

Effect of low-dose oral prednisolone on symptoms and systemic inflammation in older adults with moderate to severe knee osteoarthritis: a randomized placebo-controlled trial

J. Rheumatol.