ABSTRACT
Background Cytomegalovirus (CMV) reactivation may occur as the shedding of the virus from various body sites or could represent an active disease that might be fatal if untreated. Distinguishing between the two states may prove very difficult. The role of the CMV disease in patients with hematological malignancies or transplant patients is more defined than that in other immunocompromised patients where neither anti-CMV prophylaxis is used nor plasma CMV levels are monitored. Here, we try to examine cases with CMV viremia in the latter group of patients in an attempt to make a distinction between CMV infection and disease to determine which patients would benefit from treatment. Methods Elderly patients, patients with rheumatological disorders, and patients with inflammatory bowel disease (IBD) and with clinical suspicion of CMV disease who were referred to the infectious diseases service at Sultan Qaboos University Hospital were examined from 1 January 2018 to 31 January 2023. We added a patient we found in our referral log book from 2012. Clinical, epidemiological, and laboratory data were retrieved from the hospital information system. Plasma CMV levels and CMV body fluid levels including pulmonary samples obtained from bronchoalveolar lavage (BAL) in suspected cases of CMV pneumonitis and gastrointestinal (GI) CMV levels obtained from stool and gastrointestinal tissue biopsies in suspected cases of gastrointestinal CMV disease were collected. COBAS® AmpliPrep/COBAS® TaqMan®assay (Roche Molecular Systems, Inc., Branchburg, NJ) was used to measure CMV copies per milliliter. Results A total of 28 patients were considered to have CMV disease, 12 of whom were elderly (≥60 years) and the rest were young and middle aged (Y/M). The most common comorbidities of the elderly included chronic kidney disease (CKD), hypertension (HTN), and diabetes mellitus (DM). In the Y/M group, seven patients had systemic lupus erythematosus (SLE), one had antineutrophil cytoplasmic antibody (ANCA) associated vasculitis, four patients had IBD, two had IBD plus primary immunodeficiencies (one patient had agammaglobulinemia and one had combined deficiencies), and one patient had combined immunodeficiency. CKD was a common finding in the SLE patients. Diarrhea was the most common CMV presentation occurring in 19 patients (67.9%), being bloody in 10 patients. Four patients had pulmonary presentations, and four had hematological presentations in the form of anemia or pancytopenia. Nineteen patients were given CMV antiviral treatment, and one patient received it during the first episode but not in the second episode. Twenty-eight-day mortality in the treated group was 20% versus 55.5% in the untreated group. The majority of the deaths occurred in the SLE and elderly patients. Thrombocytopenia occurred in 60.7%, 70.6% of whom died signaling a potential predictive role for thrombocytopenia in early empirical CMV antiviral treatment and in prognosis. Conclusion The difficulty in distinguishing CMV infection from CMV disease remains a concern in the elderly and SLE patients. In our small study, there was a survival benefit in early screening for CMV and initiating preemptive CMV antiviral therapy in these two groups even before CMV disease is proven. This urgency was not observed for patients with IBD or primary immunodeficiencies. A major common factor for CMV disease was CKD, whereas thrombocytopenia was an indicator of disease and prognosis.
ABSTRACT
AIM: This study is a longitudinal multicenter study which aims to find the prevalence, the demographic data, survival and mortality rates of patients with systemic lupus erythematosus (SLE) in Oman. METHOD: All Omani patients, pediatrics and adults diagnosed with SLE, who fulfill either the 1997 American College of Rheumatology or Systemic Lupus International Collaborating Clinics classifications criteria for SLE were included from January 2006 till February 2020. RESULTS: In total 1160 patients were included in this cohort. Data analysis showed that patient's ages ranged from 2-82 years with female predominance and female-to-male ratio of 7:1 (87.7% female,12.3% male). The mean prevalence of SLE among different age groups was 38.8 (range 5-63 per 100 000 inhabitants). The mortality rate was found to be 5%. Male patients had significantly higher mortality rate than females (7.6% vs 5.4%, P value = .04). Sepsis was the commonest cause of mortality (34%). The coexistence of systemic sclerosis correlates significantly with death (P = .002). Survival analysis in our data showed 5, 10, 20, 40-year survival rates of 100%, 100%, 99% and 90% respectively for antinuclear antibody (ANA) positive patients and lower survival rate for ANA negative patients with 5,10, 20, 40-year survival rates of 100, 99%, 99% and 75%, respectively. CONCLUSION: This study showed that the mean prevalence of SLE in Oman to be 38.8 (range 5-63) per 100 000 inhabitants. The 40-year survival rate among patients with positive ANA was found to be 90%, while patients with negative ANA had worse survival outcomes.
