Autoimmune inflammatory disorders, systemic corticosteroids and pneumocystis pneumonia: A strategy for prevention

BACKGROUND: Pneumocystis pneumonia (PCP) is an increasing problem amongst patients on immunosuppression with autoimmune inflammatory disorders (AID). The disease presents acutely and its diagnosis requires bronchoalveolar lavage in most cases. Despite treatment with intravenous antibiotics, PCP carries a worse prognosis in AID patients than HIV positive patients. The overall incidence of PCP in patients with AID remains low, although patients with Wegener's granulomatosis are at particular risk. DISCUSSION: In adults with AID, the risk of PCP is related to treatment with systemic steroid, ill-defined individual variation in steroid sensitivity and CD4+ lymphocyte count. Rather than opting for PCP prophylaxis on the basis of disease or treatment with cyclophosphamide, we argue the case for carrying out CD4+ lymphocyte counts on selected patients as a means of identifying individuals who are most likely to benefit from PCP prophylaxis. SUMMARY: Corticosteroids, lymphopenia and a low CD4+ count in particular, have been identified as risk factors for the development of PCP in adults with AID. Trimethoprim-sulfamethoxazole (co-trimoxazole) is an effective prophylactic agent, but indications for its use remain ill-defined. Further prospective trials are required to validate our proposed prevention strategy

The burden and measurement of cardiovascular disease in SSc

The prognosis for patients with systemic sclerosis (SSc) has improved in the past three decades, with fewer patients succumbing to renal-crisis-related death. While pulmonary fibrosis and hypertension are currently the most frequent causes of death, there is evidence that cardiovascular disease will have an important role in the long-term prognosis of SSc in the future. Ischemia-reperfusion injury and endothelial dysfunction are cardinal features of SSc, and may predispose a patient to microvascular disease and atherosclerosis. In order to alleviate the cardiovascular burden in patients with SSc, it is important to detect endothelial dysfunction, microvascular flow disturbance and atherosclerosis. Noninvasive techniques that evaluate flow-mediated dilatation and arterial pulse waves (endothelial function measurements), microvascular blood flow (measurement of the microcirculation), carotid intima-media thickness and left ventricular hypertrophy (detection of atherosclerosis) are recommended. In addition, these measurements will facilitate trials of therapeutic strategies that, in addition to controlling conventional risk factors, prevent and treat cardiovascular disease in patients with SSc. © 2010 Macmillan Publishers Limited. All rights reserved.link_to_subscribed_fulltex