CMV infection in active systemic lupus erythematosus: clinical characteristics, prognosis and treatment outcomes

OBJECTIVE: To identify factors associated with, and treatment outcomes of Cytomegalovirus (CMV) infection in patients with active systemic lupus erythematosus (SLE). METHODS: SLE patients treated with glucocorticoids, with/without immunosuppressive drugs who still had persistently active disease, were identified. All patients who were suspected of having CMV infection and tested for CMV PCR were enrolled. Clinical and laboratory characteristics, SLE disease activity (SLEDAI-2 K) and treatment outcomes were collected. One-year mortality was compared between CMV-infected and non-infected patients. RESULTS: 103 SLE patients were included. Thirty-seven (35.9%) had CMV infection (DNAemia); CMV disease (group 1) n = 6, symptomatic CMV infection (group 2) n = 8 and CMV infection coexisting with active SLE (group 3) n = 23. Significant characteristics of patients with CMV infection included higher SLEDAI-2 K, proteinuria, lymphopenia, thrombocytopenia, AIHA, alopecia, pleuritis, low C3, higher prednisolone dose, treatment with mycophenolate mofetil and cyclosporine. Multivariable analysis revealed that proteinuria (OR6.95; 95%CI 1.29–37.59; p = 0.024), low C3 (OR5.30; 95%CI 1.09–25.76; p = 0.039) and 30-day-average prednisolone dose > 20 mg/day (OR8.01; 95%CI 1.54–41.63; p = 0.013) were associated with CMV infection. Among non-surviving patients, 8/9(88.9%) had CMV infection. CMV was the direct cause of death in 2 patients and indirect cause in 6 (bacterial sepsis and active disease). Despite ganciclovir treatment, mortality rate was higher in patients in group 1 (66%) compared to group 2 and group 3 (12%). However, fever, leucopenia, nephrotic syndrome, rapidly progressive glomerulonephritis and lung hemorrhage mimic lupus flare, can be reversed after antiviral treatment. CONCLUSIONS: Different clinical presentations, prognosis and clinical outcomes were identified in SLE patients with CMV infection. After treatment with antiviral therapy, symptomatic CMV infection was associated with the best prognosis. CMV disease was associated with worst prognosis. CMV infection coexisting with active SLE was the most common type of CMV infection in active SLE. This group was associated with variable prognosis according to the clinical context.