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

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 On day 17, after the calf and back wounds were completely healed, the antibiotic was withdrawn.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.