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Good Response of Lupus Hepatitis to Mycophenolate Mofetil and Belimumab as of Lupus Exanthema to Rituximab: A Case Report

Psenak O, Benke AS, Haufe H, Greil R

A 66-year-old male patient had been primarily treated for cutaneous lupus erythematosus 15 years ago. He received local corticosteroids and following systemic immunosuppressants: methylprednisolone (MP), chloroquine (removed due to retinal haemorrhage), cyclosporine A and azathioprine (both removed due to non-response). Due to polyarthralgia methotrexate as well as golimumab were started. Despite good response, both drugs had to be stopped due to development of hepatitis confirmed by liver biopsy (virus serological tests were negative).

Early after onset of a combination treatment with 1 g mycophenolate mofetil (MMF) per day orally and 10 mg/kg belimumab intravenously at weeks 0, 2, 4, followed by every 4 weeks, a marked decrease in liver enzymes could be detected. Due to insufficient response of lupus exanthema, hydroxychloroquine (HCQ) was added.

After 9 months of belimumab administration, the biologic therapy was switched to rituximab (1000 mg intravenously at weeks 0 and 2) in order to achieve a better control of cutaneous manifestation. Surprisingly, after the very first infusion a rapid and marked improvement of lupus exanthema was noticed. Such an improvement had not been experienced since 2003.

We could confirm an excellent response of systemic lupus erythematosus (SLE)-associated hepatitis as well as arthralgias to MMF and belimumab. Additionally, there was an excellent and prompt response of SLE-associated skin lesions to rituximab and MMF, despite the fact, that these drugs are still not approved for treatment of SLE. Verbal informed consent was obtained from the patient for the presentation of his disease course and images.