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Challenges in administering immunosuppressive therapy in severe bacterial infection interfering crisis and refractory childhood systemic lupus erythematosus

  • Dewa Ayu Angga Rainingsih ,
  • Ketut Dewi Kumara Wati ,
  • I Wayan Gustawan ,
  • Gusti Ayu Putu Nilawati ,


Abstract

Background: Childhood Systemic Lupus Erythematosus (cSLE) mostly come with severe manifestation compared to the adult. Infection aggravated the multisystem inflammation and interfering immunosuppressive agent protocol.

Case: A 12-year-old girl was hospitalized for a month with massive edema and fever after being diagnosed with nephrotic syndrome and taken prednison for four weeks. The patient was completely bedridden, presented with hypertension, large erythematous striae across the trunk and limbs, and darkened skin. Further evaluation showed the EULAR/ACR classification criteria for SLE with score of 26. Cellulitis was suspected when a red, pinprick-sized papule appeared on the patient's right leg be increased significantly in size within two hours. Following the collection of a wound culture and blood culture specimen, triple antibiotics were given. Seven days after the wound has healed, administered of cyclophosphamide was started. Cyclophosphamide is used as an emergency treatment for lupus crises, as she experienced seizure and delirium. Seven days after cyclophosphamide administration, the wound was revived. Initial blood and wound cultures indicated an infection caused by Serratia marcescens; however, the second wound culture revealed infections caused by Klebsiella oxytoca and Enterobacter cloacae. We commenced Meropenem based on a sensitivity test to establish protection for the following administration of high-dose methylprednisolone with rituximab and cyclophosphamide. The lupus crisis was precipitated by an infection-induced inflammatory response. On day 17, after the calf and back wounds were completely healed, the antibiotic was withdrawn. In order to protect organ functionality, physiotherapy and nutritional support were employed.

Conclusion: Clinicians need to be mindful and closely observe patient with severe SLE accompanied with infection to balancing intervention for immunosuppressant therapy and antibiotic.

Keywords: systemic lupus erythematosus infection immunosuppressive therapy

References

  1. Petty RE, Laxer RM, Lindsley CB, Wedderburn LR. Text book of pediatric rheumatology 7th Ed. 2016: p.285-317.
  2. Khawaja ES and Zletni MA. Systemic Lupus Erytematosus in Libyan Children : Diagnosis and Management. iMedPub Journals. 2018;10(3):1-5. DOI: 10.21767/1989-5216.1000276.
  3. Rahman SA, Islam MI, Talukder MK, Islam M, Huque SS, et al. Presentation of childhood systemic lupus erythematosis in a tertiary care hospital. Bangladesh J Child Health. 2014;38:p.124-9. DOI: 10.3329/bjch.v38i3.22819.
  4. Aringer M, Costenbader K, Daikh D, Brinks R, Mosca M et al. 2019 European League Agains Rheumatism/American College of Rheumatology Classification Criteria for Systemic Lupus Erythematosus. Arthritis & Rheumatology. 2019;71(9):1400-12. DOI: 10.1002/art.40930.
  5. Narayanan CK, Marwaha CK, Shanmuganandan CK, Shankar GC. Correlation between systemic lupus erythematosus disease activity index, C3, C4 and Anti dsDNA Antibodies. MJAFI. 2010;66:102-7. doi: 10.1016/S0377-1237(10)80118-2
  6. Harry O, Shima Yasin, Hermine Brunner. Childhood-Onset Systemic Lupus Erythematosus: A Review and Update. J Pediatr. 2018;196:22-32. DOI: 10.1016/j.jpeds.2018.01.045.
  7. Ju Yang Jung, Chang Hee Suh. Infection in systemic lupus erythematosus, similarities, and differences with lupus flare. Korean J Intern Med. 2017;32:429-38. DOI: 10.3904/kjim.2016.234
  8. Abari IS.2015. ACR/SLICC revised criteria for diagnosis of systemic lupus erythematosus. Autoimmune Dis Ther Approaches. 2015;2:114-9. DOI: 10.14437/ADTAOA-2-114.
  9. Hahn BH, McMahon MA, Wilkinson A, Fitzgerald JD, et al. American collage of rheumatology guidelines for screening, treatment, and management of Lupus Nephritis. Arthritis Care Res. 2012;64-797-808. doi: 10.1002/acr.21664.
  10. Levy DM and Kamphuis Sylvia. Systemic Lupus Erythematosus in Children and Adolescents. Pediatr Clin North Am. 2012; 59(2): 345–64. DOI: 10.1016/j.pcl.2012.03.007.
  11. Luo Kai Ling, Yang Yao Hsu, Lin Yu Tsan, Hu Ya Chiao, Yu Hsin Hui, Wang Li Chieh Wang, Chiang Bor Luen, Lee Jyh Hong. Differential parameters between activity flare and acute infection in pediatric patients with systemic lupus erythematosus. Nature Research. 2020;20:1-14. DOI: 10.1038/s41598-020-76789-6
  12. Torrente-Segarra V, Salman-Monte TC, Rúa-Figueroa Í, et al. Associated factors to serious infections in a large cohort of juvenile-onset systemic lupus erythematosus from Lupus Registry (RELESSER). Seminars in Arthritis and Rheumatism. 2020; 50: 657-62. DOI: 10.1016/j.semarthrit.2020.05.016

How to Cite

Dewa Ayu Angga Rainingsih, Ketut Dewi Kumara Wati, I Wayan Gustawan, & Gusti Ayu Putu Nilawati. (2022). Challenges in administering immunosuppressive therapy in severe bacterial infection interfering crisis and refractory childhood systemic lupus erythematosus. Intisari Sains Medis, 13(3), 811–815. https://doi.org/10.15562/ism.v13i3.1518
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Dewa Ayu Angga Rainingsih
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Ketut Dewi Kumara Wati
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I Wayan Gustawan
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Gusti Ayu Putu Nilawati
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