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Whether it is bacteria or viruses, pneumonia is not invincible
.
Written by Gui Zhi
As more and more people around him can not escape a "yang", anxiety and uneasiness gradually spread among the population, especially for rheumatic immune disease patients, it seems that the end of the world is coming
.
However, with the anxiety of social media, people have gradually changed from fear of "yang" to fear of pneumonia
.
Pneumonia is an acute inflammation of the lungs caused by infection with different pathogens, such as bacteria, mycobacteria, viruses, fungi or parasites, but rheumatism patients do not need to panic too much, do these things, this winter will not be too difficult
.
How fragile are the lungs of rheumatologists?
Because many rheumatological causes are closely related to immune dysfunction, multiple organs may be affected in rheumatology patients, i.
e.
, rheumatism patients are at risk
of systemic involvement.
As an example, although rheumatoid arthritis (RA) is dominated by symmetric polyarthritis, interstitial lung disease (ILD) is one of the most common extra-articular manifestations in patients with RA, with pulmonary involvement in approximately 10 to 50 percent of patients with RA [1].
A study at the 2020 European Union Against Rheumatism (EULAR) Annual Meeting showed that 3.
8% of patients had ILD at the time of initial diagnosis or diagnosis of RA, while the median time to ILD episodes after RA diagnosis was 2.
3 years, of which about 47% developed ILD
within 2 years of RA diagnosis.
In addition, patients with RA may also develop pulmonary diseases
such as rheumatoid nodules and pleural effusions.
In addition to RA, patients with systemic vasculitis also show different manifestations of lung involvement depending on the type of vasculitis, the size, location, and pathology of the affected vessels, common are ILD, diffuse alveolar hemorrhage, pulmonary nodules (single or multiple, with cavitation formation), pulmonary hypertension, pulmonary aneurysm, pulmonary arteriovenous thrombosis
.
Other manifestations include pleural effusion, pleurisy, pleural nodules, pneumothorax, and emphysema
.
In addition, systemic sclerosis (SSc) is also very susceptible to lung
invasion.
The proportion of ILD in Chinese SSc patients is as high as 85.
5% [2-3], because of its insidious onset, clinical asymptomatic, and difficulty in early diagnosis, so some patients directly manifest as end-stage pulmonary fibrosis at the time of diagnosis, and pulmonary function damage is serious, which is the main cause of
death in such patients.
It can be seen that the anxiety of rheumatology patients about pneumonia is indeed groundless
.
How do rheumatism patients cope with bacterial pneumonia?
Bacterial pneumonia is most commonly caused by Streptococcus pneumoniae (gram-positive cocci) in patients of different ages, sites, and geographic regions, and immunocompromised adults are 20 times more likely to be infected [4], and rheumatic diseases due to autoimmune causes are independent risk factors for pneumococcal infection [5].
In addition, condition-modifying antirheumatic drugs (DMARDs) can increase the risk of infection, including traditional DMARDs (methotrexate, leflunomide, etc.
), biologics (adalimumab, acacacept, etc.
), and targeted drugs (tofacitinib, aplast, etc.
).
It seems that there is no way to repeat the mountains and rivers, but there is another village, because it is safe for rheumatism patients to be vaccinated with pneumococcal vaccine to prevent infection, and the vaccines that can be used to prevent pneumonia in China are mainly 13-valent pneumococcal conjugate vaccine (PCV13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23).
Guidelines recommend that immunocompromised patients aged ≥ 19 years or those receiving immunosuppressants should receive a dose of PCV13 followed by a dose of PPSV23 at least 8 weeks later; Repeat PPSV23 vaccination is recommended at least 5 years after the initial PPSV23
vaccination.
EULAR strongly recommends pneumococcal vaccination for patients with a variety of rheumatic diseases [7].
Figure 1.
The pneumonia vaccine currently approved in our country
However, rheumatism patients' lack of awareness of vaccination, other trivial interference, and unstable immune status are all obstacles to their vaccination against pneumonia
.
The latest research shows that multiple initiatives, such as repeated reminders and regular feedback, can help increase pneumococcal vaccination rates
.
How do rheumatologists cope with viral pneumonia?
It is true that many rheumatism patients' concerns about pneumonia are mainly based on new crown pneumonia, but in the situation of "should be the sun and the sun", what can be done to make rheumatism patients survive the cold winter smoothly? The protective capacity provided by vaccines remains one of
the most recommended reasons.
For adult rheumatology patients, multi-party joint decision-making can be made, and the new crown vaccine
is recommended when the condition is stable and there are no contraindications to vaccination.
Previous studies have suggested that the use of immunosuppressants may reduce the effectiveness of the vaccine, but only methotrexate, JAK inhibitors, abatacept, cyclophosphamide, and rituximab must be adjusted
when vaccinated.
Figure 2.
China's vaccination of the new crown vaccine recommends rheumatic immunological drugs that need to adjust the treatment plan
If the routine medication of rheumatology patients needs to be adjusted, the decision should be made after consultation with the doctor in charge, and the principle is: maintain the medication regimen that stabilizes the condition before infection to avoid mutations in disease activity and adverse consequences
of aggravation of the disease.
Especially hormonal drugs, the minimum dose should be used to maintain the stability of the disease, and must not be stopped rashly
.
The details are as follows:
■ People with immune or inflammatory rheumatism have a higher risk of contracting COVID after exposure than the general population, but the additional risk may be small, so there is no need to talk about "new" discoloration
.
■ Patients with rheumatism are at risk of a poor prognosis for COVID-19 and appear to be associated with
complications, treatment with glucocorticoids or rituximab, and high disease activity.
■ Patients with immune or inflammatory rheumatism and mild symptoms of new coronary pneumonia should stop taking immunomodulatory drugs
within 1-3 weeks after the onset.
■ Patients with positive or mild symptoms of new coronary pneumonia, such as risk factors for poor prognosis, should stop taking immunomodulatory drugs and consider antiviral drugs
.
■ Most patients with rheumatism who have been treated with drugs have antibody reactions to the new crown vaccine, but drugs such as B-cell depletion therapy and mycophenolate mofetil can lead to a high risk
of adverse reactions.
■ Although there is evidence of a weakened vaccine immune response in the rheumatoid population, it is still highly recommended that people with immune or inflammatory rheumatism receive the new crown vaccine, including booster shots
.
The American College of Rheumatology (ACR) recently believes [8] that before the introduction of the new crown vaccine in late 2020, the immunity of the population to the SARS–CoV-2 virus was very low, and maximizing the efficiency of the vaccine is a top priority
.
In contrast, avoiding rheumatism outbreaks is more important
when considering routine vaccination.
Face it calmly, follow the doctor's advice, scientifically prevent "lungs", do a good job of protection, winter is about to pass
.
References:
[1] ZHENG Xuejun, WANG Xiaoxia, et al.
Research progress of rheumatoid arthritis combined with lung interstitial lesions[J].
Hebei Medical Journal,2016,38(11).
[2] Walker UA, et al.
Ann Rheum Dis
2007; 66:754-63.
[3] Hu S, et al.
Arthritis Res
Ther.
2018 Oct 22; 20(1):235.
[4] Papadatou I, Spoulou V.
Pneumococcal Vaccination in High-Risk Individuals: Are We Doing It Right? Clin
Vaccine Immunol 2016; 23:388-95.
[5] Shea KM, Edelsberg J, Weycker
D, Farkouh RA, Strutton DR, Pelton SI.
Rates of pneumococcal disease in adults
with chronic medical conditions.
Open Forum Infect Dis 2014; 1:ofu024.
[6] Schurder J, Goulenok T, Jouenne
R, et al.
Pneumococcal infection in patients with systemic lupus erythematosus.
Joint Bone Spine 2018; 85:333-6.
[7] Furer V, Rondaan C, Heijstek
MW, et al.
2019 update of EULAR recommendations for vaccination in adult
patients with autoimmune inflammatory rheumatic diseases.
Ann Rheum Dis
2020; 79:39-52.
[8]Curtis J R, Johnson S R,
Anthony D D, et al.
American college of rheumatology guidance for COVID‐19 vaccination in patients with rheumatic and musculoskeletal
diseases: version 3[J].
Arthritis & Rheumatology, 2021, 73(10): e60-e75.
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