Few studies have evaluated the impact of
viral infections on the daily management of patients with
systemic lupus erythematosus (SLE). We analyzed the etiology and clinical features of acute
viral infections arising in patients with SLE and their influence on the diagnosis, prognosis, and treatment of SLE. Cases occurring within the last 5 years were selected from the databases of 3 large teaching hospitals. Acute
viral infections were confirmed by the identification of specific
antiviral IgM antibodies and subsequent seroconversion with detection of specific
IgG antibodies. In autopsy studies, macroscopic findings suggestive of
viral infection were confirmed by direct identification of the virus or viruses in tissue samples. We performed a MEDLINE search for additional cases reported between January 1985 and March 2008. We included 88 cases (23 from our clinics and 65 from the literature review) of acute
viral infections in patients with SLE. Twenty-five patients were diagnosed with new-onset SLE (fulfillment of the 1997 SLE criteria) associated with
infection by human parvovirus B19 (n = 15), cytomegalovirus (CMV; n = 6), Epstein-Barr virus (EBV; n = 3), and hepatitis A virus (n = 1). The remaining 63 cases of acute
viral infections arose in patients already diagnosed with SLE: in 18 patients, symptoms related to
infection mimicked a lupus flare, 36 patients, including 1 patient from the former group who presented with both conditions, presented organ-specific
viral infections (mainly
pneumonitis,
colitis,
retinitis, and
hepatitis), and 10 patients presented a severe, multiorgan process similar to that described in catastrophic
antiphospholipid syndrome-the final diagnosis was
hemophagocytic syndrome in 5 cases and disseminated
viral infection in 5. Twelve patients died due to
infection caused by CMV (n = 5), herpes simplex virus (n = 4), EBV (n = 2), and varicella zoster virus (n = 1). Autopsies were performed in 9 patients and disclosed disseminated herpetic
infection in 6 patients (caused by
herpes simplex in 4 cases,
varicella in 1, and CMV in 1) and
hemophagocytic syndrome in 3. A higher frequency of
renal failure (54% vs. 19%, p = 0.024),
antiphospholipid syndrome (33% vs. 6%, p = 0.023), treatment with
cyclophosphamide (82% vs. 37%, p = 0.008), and multisystemic involvement at presentation (58% vs. 8%, p < 0.001); and a lower frequency of
antiviral therapy (18% vs. 76%, p < 0.001) were found in patients who died, compared with survivors. The most common
viral infections in patients with SLE are parvovirus B19 (predominantly mimicking SLE presentation) and CMV (predominantly presenting in severely immunosuppressed patients). CMV
infection may mimic a lupus flare or present with specific organ involvement such as gastrointestinal
bleeding or pulmonary infiltrates. Other herpesviruses are common in immunosuppressed SLE patients and may produce a wide range of manifestations. Physicians should examine the pharynx, eyes, skin, and genitalia and should conduct serologic and molecular studies to improve early detection of
viral infection in patients with SLE.