Necrotizing Fasciitis: Infection Risk From Lupus Itself, Lupus Treatment
By Daniel J. DeNoon
WebMD Health News
Latest Infectious Disease News
Reviewed by Louise Chang, MD
It's estimated that 5 million people worldwide, including 1.5 million Americans, have lupus. Are they at risk of the same life-threatening infection?
WebMD asked Chaim Putterman, MD, chief of rheumatology at Montefiore Medical Center and Albert Einstein College of Medicine in the Bronx, N.Y. With colleagues Mohammad Kamran, MD, and Jane Wachs, MD, Putterman recently reported necrotizing fasciitis in eight of the 449 lupus patients treated at their hospital from 1996 through 2007.
Is necrotizing fasciitis really an infection with flesh-eating bacteria?
The bacteria that cause necrotizing fasciitis really do eat flesh. The bacteria eat away at the tissues under the skin and spread rapidly.
There's no single kind of flesh-eating bacteria. The drug-resistant staph germ called MRSA causes a particularly difficult-to-treat form, but many other bacteria may be the cause. Over half the time, more than one kind of bacteria is involved.
The infection affects the outer skin only later in the infection. That means a serious infection can be well advanced before it looks as bad as it is.
"It is this relatively normal appearance of the skin that often causes delay in diagnosis," Putterman and colleagues note in their report.
That may be why 1 in 3 patients with necrotizing fasciitis dies of the infection.
"One reason for the bad prognosis of these patients is a delay in diagnosis," Putterman says. "That comes from a delay in patients seeking care as well as a delay in doctors making a diagnosis."
Is a person with lupus at increased risk of infection with flesh-eating bacteria?
Yes, for two reasons.
First, lupus itself makes a person more likely to get all kinds of infections, from colds to skin wounds.
That's ironic, because lupus itself is caused by a hyperactive immune system that turns against a person's own body. But the disease also involves a defective immune response to bacteria and to viruses.
The second reason is that immunity-suppressing drugs really help people with lupus.
"But patients pay a price: side effects. And the most common side effect is infection," Putterman says. "Lupus drugs suppress the same immune responses needed to protect you against foreign invaders such as bacteria."
Are people with lupus at higher risk of necrotizing fasciitis than other people with immune suppression?
That's not yet clear, because infection with flesh-eating bacteria is so rare. But Putterman's team was able to find eight cases in lupus patients at a single hospital.
This suggests "that a heightened awareness is warranted, particularly among lupus patients who are immunosuppressed by virtue of their underlying disease, the therapy they require, or both," Putterman and colleagues write in their report.
I have lupus. What can I do to cut my risk of infection with flesh-eating bacteria?
Over time, a person with lupus may have fewer or more symptoms. This means that a person with lupus doesn't always need the same dose of immune-suppressing drugs.
It's extremely important for lupus patients to regularly see a doctor with experience treating the disease. With regular checkups, lupus patients can be sure they are getting the right dose of medication.
Too much medication puts a lupus patient at risk of infection from unnecessary immune suppression. Too little medication puts a lupus patient at risk of infection from unnecessarily severe disease.
"If you get regular follow-up with a doctor who treats lupus, they would make sure you are getting the specific amount of treatment you need for your disease and no more," Putterman says. "We constantly battle to find the most effective dose of medication without over-suppressing the immune system."
I have lupus. What should I do if I think I might have necrotizing fasciitis?
There's no reason for people with lupus to run to the emergency room after every paper cut, Putterman says. But everyone, lupus patients included, should know that necrotizing fasciitis moves very, very fast.
"If you are treated for an infection and things are getting worse -- especially if you are taking immune suppressants or have a disease of the immune system -- take care of this as soon as possible," he says. "This is not the kind of infection where you say, 'It's Friday afternoon; I'll see the doc on Monday.' For this disease, hours make a difference."
SOURCES: Kamran, M. Seminars in Arthritis and Rheumatism, 2008.Chaim Putterman, MD, chief of rheumatology, Montefiore Medical Center and Albert Einstein College of medicine, Bronx, N.Y.
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