Type of publication:
Conference abstract
Author(s):
*Jayasekera H.S.; Askari A.; *Chand S.
Citation:
Clinical Medicine, Journal of the Royal College of Physicians of London. Conference: Medicine 2025: The future of medicine. RCP annual conference. 11 St Andrews Pl, London United Kingdom. 25(4 Supplement) (no pagination), 2025. Article Number: 100376. Date of Publication: 01 Jul 2025.
Abstract:
Introduction: Systemic lupus erythematosus (SLE) is a complex autoimmune disease with a wide spectrum of severity, ranging from mild manifestations to life-threatening organ damage. Its multisystem involvement poses a significant treatment challenge, because interventions targeting one organ system may inadvertently impact another. The Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) is a widely used tool for assessing disease activity, with a score above 12 indicating severe disease. However, studies estimate that approximately 20% of patients present with severe manifestations at diagnosis. One of the most serious complications of SLE is lupus nephritis, which is classified into six classes by the International Society of Nephrology/Renal Pathology Society (ISN/RPS), ranging from Class I (minimal-mesangial lupus nephritis) to Class VI (advanced-sclerosing lupus nephritis). We present a case of a patient newly diagnosed with severe SLE and lupus nephritis, characterised by high disease activity and multisystemic involvement. This case highlights the complex treatment considerations necessary when managing severe lupus.
Method(s): A 62-year-old woman presented with flu-like symptoms followed by a malar rash, mouth ulcers, fatigue, alopecia and pancytopenia. She was diagnosed with SLE with lupus nephritis confirmed by renal biopsy, and SLE on skin biopsy. Management required significant consideration because of high disease activity (SLEDAI 16) complicated by pancytopenia and liver dysfunction. Therapeutic options were systematically evaluated to balance efficacy and safety given the patient's pancytopenia, liver dysfunction and renal involvement. Mycophenolate mofetil (MMF), effective for lupus nephritis, was excluded because of its potential to worsen pancytopenia. Azathioprine, suitable for mild renal involvement, was ruled out because of liver dysfunction. Cyclophosphamide, typically used for severe SLE, was contraindicated because of its haematological and hepatic toxicity. Tacrolimus was considered for renal SLE, given the biopsy Class of I, but was unsuitable for non-renal lupus without MMF. Belimumab, an FDA-approved agent with steroid-sparing effects and a favourable safety profile, was considered but deemed challenging because of its slower onset of action and approval barriers. Hydroxychloroquine (300 mg daily) and corticosteroids (40 mg prednisolone) were ultimately chosen as the safest and most effective initial therapy. Close liaision with the renal team was essential to optimise management. Results and Discussion: Laboratory results revealed low complements (C3 0.38 g/L, C4 0.03 g/L), pancytopenia (WBC 1.2 x 109/L, platelets 126 x 109/L), elevated ferritin (5,490 mug/L), and positive dsDNA. Skin biopsy was consistent with SLE and renal biopsy confirmed lupus nephritis (ISN/RPS Class I). CT-TAP imaging showed axillary lymphadenopathy without malignancy. This case highlights the challenges of managing multisystemic lupus presenting with renal and non-renal SLE symptoms of varying degree, in a patient not already established on baseline treatment. Hydroxychloroquine and corticosteroids formed the cornerstone of treatment, while other options were systematically excluded based on contraindications. Multidisciplinary collaboration was pivotal in tailoring therapy.
Conclusion(s): There are two key learning points highlighted in this case. First, that treating multisystemic lupus requires understanding the degrees of individual organ involvement to determine immunosuppressive needs. Second, that management decisions should balance efficacy and toxicity, guided by interdisciplinary input6 and renal biopsy findings to inform immunosuppression.
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