Background: Patients with systemic lupus erythematosus (SLE) frequently experience infections (14-50%), which are a major cause of mortality (25%). The prevalence of tuberculosis (TB) infection in SLE patients is approximately 3.59%, with higher rates in regions such as Asia, Africa, and Latin America. Frequently, our practice encounters subjects with both TB and severe lupus activity, posing a significant challenge to management due to limitations in the use of high-intensity immunosuppression.

Case presentation: A 29-year-old woman with a history of SLE and triple-positive obstetric antiphospholipid syndrome, presented with disseminated Mycobacterium tuberculosis infection and active lupus complicated by severe thrombocytopenia. Non-immune causes of thrombocytopenia were excluded and the patient required multiple platelet transfusions. Antituberculous treatment was initiated, and for severe thrombocytopenia intravenous immunoglobulin was given for 5 days. Despite this intervention, platelet counts remained below 10,000/µL. With approval from infectious disease specialists, the patient received pulse methylprednisolone (250 mg IV daily for 3 days), followed by high-dose oral steroids and cyclosporine. Persistent severe thrombocytopenia prompted a bone marrow examination, which revealed marrow suppression without evidence of infection or malignancy. Given the refractory thrombocytopenia and the contraindication for eltrombopag, treatment with rituximab (RTX) 1g and mycophenolate mofetil (MMF) 500 mg bid was initiated, then tapered to 1000 mg bid. Despite adequate tolerance, platelet counts showed minimal improvement with counts persistenly below 10,000/µL. Ultimately, splenectomy was required. Three days after the procedure platelets counts were 268,000/µL.

Learning points for clinical practice: The bidirectional relationship between SLE and TB is well-documented. TB has been demonstrated to induce the production of Toll-like receptor ligands, thereby enhancing the autoimmune response. Conversely, SLE and its treatment predispose to TB infection. A higher risk of TB has been described specifically in patients with hematologic SLE, particularly those with lymphopenia and thrombocytopenia, where the risk of disseminated infection is significantly increased. Treatment must be carefully managed as intensive immunosuppression can worse the infection. However, in cases refractory to first-line agents such as immunoglobulins or glucocorticoids, the use of other medications like MMF or RTX may be necessary. This case contributes to the limited literature on the use of high-intensity immunosuppression, which has demonstrated favorable safety profiles.

REFERENCES: NIL.

Acknowledgements: Clinica Universitaria Bolivariana.

Disclosure of Interests: None declared.

© The Authors 2025. This abstract is an open access article published in Annals of Rheumatic Diseases under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ). Neither EULAR nor the publisher make any representation as to the accuracy of the content. The authors are solely responsible for the content in their abstract including accuracy of the facts, statements, results, conclusion, citing resources etc.