Información de la revista
Vol. 4. Núm. S2.
Monográfico: Infección y patologías microcristalinas
Páginas 1-6 (Octubre 2008)
Compartir
Compartir
Descargar PDF
Más opciones de artículo
Vol. 4. Núm. S2.
Monográfico: Infección y patologías microcristalinas
Páginas 1-6 (Octubre 2008)
Infección y patologías microcristalinas
Acceso a texto completo
Infecciones en el paciente inmunodeficiente. ¿Qué papel tienen los fármacos?
Infections in the Immunocompromised Host. What Is the Role of the Medications?
Visitas
5792
Antonio Ramos
Autor para correspondencia
antrammar@yahoo.es

Correspondencia: Dr. A. Ramos. Unidad de Enfermedades Infecciosas-Medicina Interna. Hospital Universitario Puerta de Hierro. Universidad Autónoma de Madrid. San Martín de Porres, 4. 28035 Madrid. España.
Unidad de Enfermedades Infecciosas-Medicina Interna. Hospital Universitario Puerta de Hierro. Universidad Autónoma de Madrid. Madrid. España
Este artículo ha recibido
Información del artículo
Resumen
Bibliografía
Descargar PDF
Estadísticas

Las infecciones en pacientes con enfermedades del tejido conectivo (ETC) conllevan una morbilidad y una mortalidad considerables. Algunos pacientes con ETC sufren cierto grado de desregulación inmunitaria inherente a su enfermedad reumática. Otros factores como la edad avanzada o el curso de otras enfermedades crónicas –como la diabetes mellitus– también pueden favorecer el desarrollo de infecciones. Los glucocorticoides inducen una disminución en la síntesis de la mayoría de las citocinas conocidas, una alteración de la migración de los leucocitos desde el torrente sanguíneo que afecta a la presentación de antígenos y deteriora la respuesta citotóxica. Los inmunosupresores afectan fundamentalmente a la inmunidad celular y su efecto está relacionado con la duración y la dosis empleada. Se ha observado una relación clara entre el empleo de fármacos contra el factor de necrosis tumoral (anti-TNF) y la reactivación de la tuberculosis. Sus manifestaciones clínicas e histológicas con frecuencia son atípicas. En casos de sospecha de tuberculosis activa, los anti-TNF deben suspenderse hasta descartar la infección. El tratamiento profiláctico contra Pneumocystis jiroveci con cotrimoxazol ha sido recomendado en pacientes que reciben glucocorticoides junto con inmunosupresores, especialmente si el agente usado es ciclofosfamida o si se produce linfocitopenia.

Palabras clave:
Infliximab
Infecciones oportunistas
Tuberculosis
Pacientes inmunodeficientes

Infections in patients with connective tissue diseases (CTD) are associated to considerable morbidity and mortality. Some patients with CTD suffer a certain degree of immune deregulation inherent to their rheumatic disease. Other factors such as advanced age, and the coexistence of other chronic diseases such as diabetes mellitus can also lead to the development of infection. Glucocoticosteroids induce a reduction in the synthesis of most of the known cytokines, an alteration in the migration of leukocytes from the blood with an alteration in antigen presentation and an abnormal cytotoxic response. Immunosuppresants fundamentally affect cellular immunity and its effect is related to the duration of treatment and dose. There is a clear relationship between the use of anti-TNF drugs and the reactivation of tuberculosis. Its clinical and histological manifestations are frequently atypical. In those cases in which active tuberculosis is suspected, anti-TNF must be suspended until infection is ruled out. Prophylactic treatment when faced with Pneumocystis jiroveci with cotrimoxazole has been recommended in patients that receive steroids and immunosuppressants, especially if the agent employed is cyclophosphmide or if lymphopenia develops.

Key words:
Infliximab
Opportunistic infections
Tuberculosis
Immunocompromised hosts
El Texto completo está disponible en PDF
Bibliografía
[1.]
M.E. Falagas, K.G. Manta, B.I. Betsi, G. Pappas.
Infection-related morbidity and mortality in patients with connective tissue diseases: a systematic review.
Clin Rheumatol, 26 (2007), pp. 663-670
[2.]
E. Sowden, A.J. Carmichael.
Autoimmune inflammatory disorders and pneumocystis pneumonia: a strategy for prevention.
BMC Infect Dis, 4 (2004), pp. 42-46
[3.]
J.S.H. Gaston, A.B. Rickinson, Q.Y. Yao, M.A. Epstein.
The abnormal cytotoxic T cell response to Epstein-Barr virus in rheumatoid arthritis is correlated with disease activity and occurs in other arthropathies.
Ann Rheum Dis, 45 (1986), pp. 932-936
[4.]
P.J. Staples, D.N. Gerding, J.L. Decker, R.S. Gordon Jr.
Incidence of infection in systemic lupus erythematosus.
Arthritis Rheum, 17 (1974), pp. 1-10
[5.]
R.M. Feischmann, S.W. Baumgartner, E.A. Tindall, A.L. Weaver, L.W. Moreland, M.H. Schiff, et al.
Response to etanercept (Enbrel) in elderly patients with rheumatoid arthritis: a retrospective analysis of clinical trial results.
J Rheumatol, 30 (2003), pp. 691-696
[6.]
P. Marrack, J. Kappler.
Subversion of the immune system by pathogens.
Cell, 76 (1994), pp. 323-332
[7.]
T. Rhen, J.A. Cidlowski.
Antiinflammatory action of glucocorticoids — new mechanisms for old drugs.
N Engl J Med, 353 (2005), pp. 1711-1723
[8.]
D.T. Boumpas, G.P. Chrousos, R.L. Wilder, T.R. Cupps, J.E. Balow.
Glucocorticoid therapy for immune-mediated diseases: basic and clinical correlates.
Ann Intern Med, 119 (1993), pp. 1198-1208
[9.]
T.L. Gerrard, T.R. Cupps, C.H. Jurgensen, A.S. Fauci.
Hydrocortisone-mediated inhibition of monocyte antigen presentation: Dissociation of inhibitory effect and expression of DR antigens.
Cell Immunol, 85 (1984), pp. 330-339
[10.]
M.E. Fedor, A. Rubinstein.
Effects of long-term low-dose corticosteroid therapy on humoral immunity.
Ann Allergy Asthma Immunol, 97 (2006), pp. 113-116
[11.]
K.G. Saag, R. Koehneke, J.R. Caldwell, R. Brasington, L.F. Burmeister, B. Zimmerman, et al.
Low dose long-term corticosteroid therapy in rheumatoid arthritis: an analysis of serious adverse events.
Am J Med, 96 (1994), pp. 115-123
[12.]
S. Rosner, E.M. Ginzler, H.S. Diamond, M. Weiner, M. Schlesinger, J. Fries, et al.
A multicenter study of outcome in systemic lupus erythematosus. II. Causes of death.
Arthritis Rheum, 25 (1982), pp. 612-617
[13.]
V. Noel, O. Lortholary, P. Casassus, P. Cohen, T. Genereau, M.-H. Andre, et al.
Risk factors and prognostic influence of infection in a single cohort of 87 adults with systemic lupus erythematosus.
Ann Rheum Dis, 60 (2001), pp. 1141-1144
[14.]
H. Badsha, K.O. Kong, T.Y. Lian, S.P. Chan, C.J. Edwards, H.H. Chng.
Lowdose pulse methylprednisolone for systemic lupus erythematosus flares is efficacious and has a decreased risk of infectious complications.
Lupus, 11 (2002), pp. 508-513
[15.]
K.N. Duffy, C.M. Duffy, D.D. Gladman.
Infection and disease activity in systemic lupus erythematosus: a review of hospitalised patients.
J Rheumatol, 18 (1991), pp. 1180-1184
[16.]
D.B. Hellmann, M. Petri, Q. Whiting-O’Keefe.
Fatal infections in systemic lupus erythematosus: the role of opportunistic organisms.
Medicine (Baltimore), 66 (1987), pp. 341-348
[17.]
P. Lee, M.B. Urowitz, A.A. Bookman, M. Bookman, B. Koehler, H. Smythe, et al.
Systemic lupus erythematosus. A review of 110 cases with reference to nephritis, the nervous system, infections, aseptic necrosis and prognosis.
Q J Med, 46 (1977), pp. 1-32
[18.]
M. Petri, M. Genovese.
Incidence of and risk factors for hospitalisations in systemic lupus erythematosus: a prospective study of the Hopkins lupus cohort.
J Rheumatol, 19 (1992), pp. 1559-1565
[19.]
J.E. Yun, S.W. Lee, T.H. Kim, J.B. Jun, S. Jung, S.C. Bae, et al.
The incidence and clinical characteristics of Mycobacterium tuberculosis infection among systemic lupus erythematosus and rheumatoid arthritis patients in Korea.
Clin Exp Rheumatol, 20 (2002), pp. 127-132
[20.]
H.A. Kim, C.D. Yoo, H.J. Baek, E.B. Lee, C. Ahn, J.S. Han, et al.
Mycobacterium tuberculosis infection in a corticosteroid-treated rheumatic disease patient population.
Clin Exp Rheumatol, 16 (1998), pp. 9-13
[21.]
B.D. Gescuk, J.C. Davis Jr.
Novel therapeutic agents for systemic lupus erythematosus.
Curr Opin Rheumatol, 4 (2002), pp. 515-521
[22.]
F.A. Houssiau, C. Vasconcelos, D. D’Cruz, G.D. Sebastiani, E.R. Garrido, M.G. Danieli, et al.
Immunosuppressive therapy in lupus nephritis: the Euro-Lupus Nephritis Trial, a randomized trial of low-dose versus high-dose intravenous cyclophosphamide.
Arthritis Rheum, 46 (2002), pp. 2121-2131
[23.]
A. Warris, A. Bjørneklett, P. Gaustad.
Invasive pulmonary aspergillosis associated with infliximab therapy.
N Engl J Med, 344 (2001), pp. 1099-1100
[24.]
O. Nived, G. Sturfel, F. Wollheim.
Systemic lupus erythematosus and infection: a controlled and prospective study including an epidemiologic group.
Q J Med, 55 (1985), pp. 271-287
[25.]
B.H. Segal, M.C. Sneller.
Infectious complications of immunosuppressive therapy in patients with rheumatic diseases.
Rheum Dis Clin North Am, 23 (1997), pp. 219-237
[26.]
K.S. Kanik, J.M. Cash.
Does methotrexate increase the risk of infection or malignancy?.
Rheum Dis Clin North Am, 23 (1997), pp. 955
[27.]
D.E. Furst, F.C. Breedveld, J.R. Kalden, J.S. Smolen, G.R. Burmester, J. Sieper, et al.
Updated consensus statement on biological agents for the treatment of rheumatic diseases, 2007.
Ann Rheum Dis, 66 (2007), pp. iii2-iii22
[28.]
A.Y. Chan, L.S. Hooi.
Outcome of 85 lupus nephritis patients treated with intravenous cyclophosphamide: a single centre 10 year experience.
Med J Malaysia, 55 (2000), pp. 14-20
[29.]
W. Hu, Z. Liu, H. Chen, Z. Tang, Q. Wang, K. Shen, et al.
Mycophenolate mofetil vs cyclophosphamide therapy for patients with diffuse proliferative lupus nephritis.
Chin Med J (Engl), 115 (2002), pp. 705-709
[30.]
M.Y. Karim, P. Alba, M.J. Cuadrado, I.C. Abbs, D.P. D’Cruz, M.A. Khamashta, et al.
Mycophenolate mofetil for systemic lupus erythematosus refractory to other immunosuppressive agents.
Rheumatology (Oxford), 41 (2002), pp. 876-882
[31.]
H.S. Oz, W.T. Hughes.
Novel anti-Pneumocystis carinii effects of the immunosuppressant mycophenolate mofetil in contrast to provocative effects of tacrolimus, sirolimus, and dexamethasone.
J Infect Dis, 175 (1997), pp. 901-904
[32.]
J.M. Sarmiento, D.H. Dockrell, T.R. Schwab, S.R. Munn, C.V. Paya.
Mycophenolate mofetil increases cytomegalovirus invasive organ disease in renal transplant patients.
Clin Transplant, 14 (2000), pp. 136-138
[33.]
A.M. De Mattos, A.J. Olyaei, W.M. Bennett.
Pharmacology of immunosuppressive medications used in renal transplantation.
Am J Kidney Dis, 28 (1996), pp. 631-667
[34.]
I. Kang, S.H. Park.
Infectious complications in SLE after immunosuppressive therapies.
Curr Opin Rheumatol, 15 (2003), pp. 528-534
[35.]
K.M. Sullivan, R.P. Witherspoon, R. Storb, P. Weiden, N. Flournoy, S. Dahlberg, et al.
Prednisone and azathioprine compared with prednisone and placebo for treatment of chronic graft-v-host disease: Prognostic influence of prolonged thrombocytopenia after allogeneic marrow transplantation.
Blood, 72 (1988), pp. 546-554
[36.]
J. Andersson, S. Nagy, C.G. Groth, U. Andersson.
Effects of FK506 and cyclosporin A on cytokine production studied in vitro at a single-cell level.
Immunology, 75 (1992), pp. 136-142
[37.]
R.J. Keenan, H. Konishi, A. Kawai, I.L. Paradis, D.R. Nunley, A.T. Iacono, et al.
Clinical trial of tacrolimus versus cyclosporine in lung transplantation.
Ann Thorac Surg, 60 (1995), pp. 580-584
[38.]
A.G. Hall, M.J. Tilby.
Mechanisms of action of, and modes of resistance to, alkylating agents used in the treatment of haematological malignancies.
Blood Rev, 6 (1992), pp. 163-173
[39.]
T.R. Cupps, L.C. Edgar, A.S. Fauci.
Suppression of human B lymphocyte function by cyclophosphamide.
J Immunol, 128 (1982), pp. 2453-2457
[40.]
E. Ginzler, H. Diamond, D. Kaplan, M. Weiner, M. Schlesinger, M. Seleznick.
Computer analysis of factors influencing frequency of infection in systemic lupus erythematosus.
Arthritis Rheum, 21 (1978), pp. 37-44
[41.]
G.G. Illei, H.A. Austin, M. Crane, L. Collins, M.F. Gourley, C.H. Yarboro, et al.
Combination therapy with pulse cyclophosphamide plus pulse methylprednisolone improves long-term renal outcome without adding toxicity in patients with lupus nephritis.
Ann Intern Med, 135 (2001), pp. 248-257
[42.]
B.D. Pryor, S.G. Bologna, L.E. Kahl.
Risk factors for serious infection during treatment with cyclophosphamide and high-dose corticosteroids for systemic lupus erythematosus.
Arthritis Rheum, 39 (1996), pp. 1475-1482
[43.]
G. Camussi, E. Albano, C. Tetta, F. Bussolino.
The molecular action of tumor necrosis factor-alpha.
Eur J Biochem, 202 (1991), pp. 3-14
[44.]
J.L. Flynn, M.M. Goldstein, J. Chan, K.J. Triebold, K. Pfeffer, C.J. Lowenstein, et al.
Tumor necrosis factor-alpha is required in the protective immune response against Mycobacterium tuberculosis in mice.
Immunity, 2 (1995), pp. 561-572
[45.]
A.A. Schuna, C. Megeff.
New drugs for the treatment of rheumatoid arthritis.
Am J Health Syst Pharm, 57 (2000), pp. 225-234
[46.]
E.H.S. Choy, G.S. Panayi.
Cytokine pathways and joint inflammation in rheumatoid arthritis.
N Engl J Med, 344 (2001), pp. 907-916
[47.]
R.S. Wallis, M.S. Broder, J.Y. Wong, M.E. Hanson, D.O. Beenhouwer.
Granulomatous infectious diseases associated with tumor necrosis factor antagonists.
Clin Infect Dis, 38 (2004), pp. 1261-1265
[48.]
J.R. Curtis, N. Patkar, A. Xie, C. Martin, J.J. Allison, M. Saag.
Risk of serious bacterial infections among rheumatoid arthritis patients exposed to tumor necrosis factor alpha antagonists.
Arthritis Rheum, 56 (2007), pp. 1125-1133
[49.]
V.P. Mohan, C.A. Scanga, K. Yu, H.M. Scott, K.E. Tanaka, E. Tsang, et al.
Effects of tumor necrosis factor alpha on host immune response in chronic persistent tuberculosis: possible role for limiting pathology.
Infect Immunol, 69 (2001), pp. 1847-1855
[50.]
J.M. García-Lechuz.
Complicaciones infecciosas asociadas al uso de fármacos antagonistas del factor de necrosis tumoral. Revisión de conjunto.
Enferm Infecc Microbiol Clin, 23 (2005), pp. 551-559
[51.]
H.L. Rieder, D.E. Snider Jr, G.M. Cauthen.
Extrapulmonary tuberculosis in the United States.
Am Rev Respir Dis, 141 (1990), pp. 347-351
[52.]
J. Keane, S. Gershon, R.P. Wise.
Tuberculosis associated with infliximab, a tumor necrosis factor α–neutralizing agent.
N Engl J Med, 345 (2001), pp. 1098-1104
[53.]
L. Carmona, J.J. Gomez-Reino, V. Rodriguez-Valverde, D. Montero, E. Pascual-Gómez, E.M. Mola, et al.
Effectiveness of recommendations to prevent reactivation of latent tuberculosis infection in patients treated with tumor necrosis factor antagonists.
Arthritis Rheum, 52 (2005), pp. 1766-1772
[54.]
W.R. Gilliland, G.C. Tsokos.
Prophylactic use of antibiotics and immunisations in patients with SLE.
Ann Rheum Dis, 61 (2002), pp. 191-192
[55.]
A. Strangfeld, J. Listing.
Infection and musculoskeletal conditions: Bacterial and opportunistic infections during anti-TNF therapy.
Best Pract Res Clin Rheumatol, 20 (2006), pp. 1181-1195
[56.]
F. Medina.
Terapia biológica e infecciones.
Reumatol Clin, 2 (2006), pp. 302-312
[57.]
M. Esteve, C. Saro, F. González-Huix, F. Suarez, M. Forné, J.M. Viver.
Chronic hepatitis B reactivation following infliximab therapy in Crohn's disease patients: need for primary prophylaxis.
Gut, 53 (2004), pp. 1363-1365
[58.]
O. Sakamoto, M. Ando, S. Yoshimatsu, H. Kohrogi, M. Suga, M. Ando.
Systemic lupus erythematosus complicated by cytomegalovirus-induced hemophagocytic syndrome and colitis.
Intern Med, 41 (2002), pp. 151-155
[59.]
A. Humar, D. Siegal, G. Moussa, D. Kumar.
A prospective assessment of valganciclovir for the treatment of cytomegalovirus infection and disease in transplant recipients.
J Infect Dis, 192 (2005), pp. 1154-1157
[60.]
U.M. Overgaard, J. Helweg-Larsen.
Pneumocystis jiroveci pneumonia (PCP) in HIV-1-negative patients: a retrospective study 2002-2004.
Scand J Infect Dis, 39 (2007), pp. 589-595
[61.]
M.E. Viney, J.B. Lok.
Strongyloides spp.
WormBook, 23 (2007), pp. 1-15
[62.]
R. Krishnamurthy, H.E. Dincer, D. Whittemore.
Strongyloides stercoralis hyperinfection in a patient with rheumatoid arthritis after anti-TNF-alpha therapy.
J Clin Rheumatol, 13 (2007), pp. 150-152
Copyright © 2008. Elsevier España S.L. Barcelona
Idiomas
Reumatología Clínica
Opciones de artículo
Herramientas
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?