Initial Assessment and Management of Patients with Systemic Lupus Erythematosus Who Receive Immunosuppressive Therapy and are Seen with Fever or Other Symptoms and Signs Suggestive of Infection

Initial Assessment and Management of Patients with Systemic Lupus Erythematosus Who Receive Immunosuppressive Therapy and are Seen with Fever or Other Symptoms and Signs Suggestive of Infection - Flowchart Systemic Lupus Erythematosus Systemic Lupus Erythematosus

«Flowchart»

Start

Fever and immunosuppressive therapy

Degree of immunosuppression

Moderate risk
Prednisone <10 mg/day MTX, AZA, MMF IV CYC

High risk
Prednisone >20 mg/day
Biologics
PO CYC
MMF plus CNI
Epidemiologic exposure
Risk for MRSA, H1N1
Opportunistic infections
Travel

Degree of immunosuppression

Moderate risk
Prednisone <10 mg/day MTX, AZA, MMF IV CYC

Moderate risk Moderate risk Moderate risk

High risk
Prednisone >20 mg/day
Biologics
PO CYC
MMF plus CNI
Epidemiologic exposure
Risk for MRSA, H1N1
Opportunistic infections
Travel

High risk High risk High risk

Epidemiologic exposure

Degree of immunosuppression

<Next Node>

Observe

Consider admit to hospital

End

Presence of WBC or comorbidities

Brain imaging
CSF examination

Neutropenia <500-1000/mm³

Broad-spectrum antibiotics G-CSF if seriously ill (pneumonia, hypotension, organ dysfunction)

End

Aggressive search for infection

CBC

Blood cultures

Chest x-ray

Urine analysis

Stool examination (if diarrhea)

Headache or altered mental status

Empiric therapy (quinolone)

Empiric therapy (antibiotics + acyclovir)^‡

^‡ ^‡

Empiric antibiotic therapy^†

^† ^†

HRCT, BAL, PCR, GM

Infiltrates

Acutely ill

Stable

Unrevealing evaluation or no response

Open lung biopsy/VATS

^*Systemic inflammatory response syndrome (SIRS): T ≥38° C or<36° C, tachycardia (heart rate >90/min), tachypnea (respiratory rate >20/min), white blood cells (WBC) >12,000/mm³; comorbidities: Age older than 65 yr, diabetes, chronic cardiopulmonary disease.

^* ≥ ³

^†Consider empiric therapy for Pneumocystis pneumonia in severe hypoxemia or diffuse pulmonary infiltrates.

^†

^‡Consider tuberculosis and other opportunistic central nervous system (CNS) infections.

^‡

T <38� C
No SIRS, no leukocytosis

T <38� C

T ≥38° C × 2 and/or SIRS or comorbidities^*

≥ ^* ^* T >=38� C × 2