Silva João E, Silva Clara, Pacheco Mariana, Pereira Edite, Almeida Jorge S
Internal Medicine, Centro Hospitalar Universitário de São João, Porto, PRT.
Medicine, Faculdade de Medicina da Universidade do Porto, Porto, PRT.
Cureus. 2021 Oct 21;13(10):e18944. doi: 10.7759/cureus.18944. eCollection 2021 Oct.
Here, we report the case of a 53-year-old man with suspected autoimmune arthritis on low-dose corticosteroid therapy. He was recently hospitalized due to presumed bacterial pneumonia and a seizure episode attributed to high fever. His condition deteriorated after discharge, and he presented to our institution with a persistent cough, weight loss, skin rash, arthralgias, fever, and altered mental status. The investigation led to the simultaneous diagnosis of a systemic lupus erythematosus (SLE) flare and disseminated tuberculosis (TB), both pulmonary and intracranial. Proteinuria and peripheral edema were identified, suggesting renal involvement of SLE. Anti-mycobacterial drugs and high-dose corticosteroid therapy were initiated. Given the risk of starting other immunosuppressive drugs in the presence of intracranial TB, in a patient with stable renal function and a significant decrease in proteinuria with corticosteroids and supportive therapy alone, renal biopsy was postponed. Prednisolone was progressively tapered down during the next six months, always maintaining anti-mycobacterial therapy, which resulted in a second SLE flare and the need to increase corticosteroids again. At this time, a renal biopsy was performed, showing class II lupus nephritis and confirming the diagnosis of SLE. After one year of anti-mycobacterial therapy with complete resolution of cerebral and pulmonary TB lesions, we chose to initiate mycophenolate mofetil as an immunosuppressive steroid-sparing agent with increased SLE control, allowing for corticosteroid reduction.
在此，我们报告一例53岁男性患者，该患者因疑似自身免疫性关节炎接受低剂量皮质类固醇治疗。他最近因疑似细菌性肺炎和高热引发的癫痫发作而住院。出院后他的病情恶化，随后因持续咳嗽、体重减轻、皮疹、关节痛、发热和精神状态改变前来我院就诊。检查结果显示同时诊断出系统性红斑狼疮（SLE）发作以及播散性肺结核（TB），包括肺部和颅内结核。发现有蛋白尿和外周水肿，提示SLE累及肾脏。于是开始使用抗分枝杆菌药物和高剂量皮质类固醇治疗。鉴于在颅内结核患者中启动其他免疫抑制药物存在风险，且该患者肾功能稳定，仅使用皮质类固醇和支持性治疗后蛋白尿显著减少，因此推迟了肾活检。在接下来的六个月中，泼尼松龙逐渐减量，同时始终维持抗分枝杆菌治疗，结果导致SLE再次发作，需要再次增加皮质类固醇剂量。此时进行了肾活检，显示为II级狼疮性肾炎，从而确诊了SLE。在抗分枝杆菌治疗一年后，脑和肺部结核病灶完全消退，我们选择开始使用霉酚酸酯作为免疫抑制药物以替代皮质类固醇，从而更好地控制SLE，得以减少皮质类固醇的用量。
