Habuka Masato, Wada Yoko, Kurosawa Yoichi, Yamamoto Suguru, Tani Yusuke, Ohashi Riuko, Ajioka Yoichi, Nakano Masaaki, Narita Ichiei
Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Chuo-ku, Niigata City, Niigata, 951-8510, Japan.
Division of Cellular and Molecular Pathology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.
BMC Res Notes. 2018 Mar 5;11(1):165. doi: 10.1186/s13104-018-3271-3.
Visceral disseminated varicella zoster viral (VZV) infection is a rare but severe complication with a high mortality rate in immunosuppressed individuals, and an increased susceptibility to VZV has been reported in kidney transplant recipients who are treated with mycophenolate mofetil (MMF). In Japan, MMF is currently approved for patients with lupus nephritis (LN) and data to indicate its optimal dosage are still insufficient.
A 46-year-old Japanese woman with rheumatoid arthritis was diagnosed as having systemic lupus erythematosus (SLE) and LN class III (A/C). Although initial remission-induction therapy with prednisolone and tacrolimus was started, her serum creatinine level and urinary protein excretion were elevated. Methylprednisolone pulse therapy was added, and tacrolimus was switched to MMF. Two months after admission when she was taking 40 mg of PSL and 1500 mg of MMF daily, she suddenly developed upper abdominal pain and multiple skin blisters, and disseminated visceral VZV infection was diagnosed. Laboratory examinations demonstrated rapid exacerbation of severe acute liver failure and coagulation abnormalities despite immediate multidisciplinary treatment, and she died of hemorrhagic shock 7 days after the onset of abdominal pain. A serum sample collected at the time of admission revealed that she had recursive VZV infection.
MMF together with high-dose glucocorticoid therapy may increase the risk of VZV infection in Asian patients with SLE. Accumulation of evidence for parameters of safety, such as the area under the blood concentration-time curve of mycophenolic acid, should be urgently considered in order to establish a safer protocol for remission induction therapy in Asian patients with LN.
内脏播散性水痘带状疱疹病毒（VZV）感染是一种罕见但严重的并发症，在免疫抑制个体中死亡率很高，据报道，接受霉酚酸酯（MMF）治疗的肾移植受者对VZV的易感性增加。在日本，MMF目前已被批准用于狼疮性肾炎（LN）患者，但其最佳剂量的数据仍然不足。
一名46岁的日本类风湿性关节炎女性被诊断为系统性红斑狼疮（SLE）和III级（A/C）LN。尽管开始了泼尼松龙和他克莫司的初始诱导缓解治疗，但其血清肌酐水平和尿蛋白排泄仍升高。加用甲泼尼龙冲击治疗，并将他克莫司换为MMF。入院两个月后，当她每天服用40mg泼尼松龙和1500mg MMF时，突然出现上腹部疼痛和多个皮肤水疱，被诊断为内脏播散性VZV感染。实验室检查显示，尽管立即进行了多学科治疗，但严重急性肝衰竭和凝血异常仍迅速加重，她在腹痛发作7天后死于失血性休克。入院时采集的血清样本显示她存在复发性VZV感染。
MMF联合大剂量糖皮质激素治疗可能会增加亚洲SLE患者发生VZV感染的风险。为了建立更安全的亚洲LN患者诱导缓解治疗方案，应紧急考虑积累诸如霉酚酸血药浓度-时间曲线下面积等安全性参数的证据。
