1 Department of Nephrology and Internal Medicine, Charles Nicolle Hospital, Tunis, Tunisia, 2 Department of Dermatology, Habib Thameur Hospital, Tunis, Tunisia and 3 Department of Immunology, Charles Nicolle Hospital, Tunis, Tunisia
Correspondence and offprint requests to: Dr Hayet Kaaroud, Department of Nephrology and Internal Medicine, Charles Nicolle Hospital, Boulevard 9 Avril 1938, 1006 BS. Tunis, Tunisia. Email: hedi.benmaiz{at}rns.tn
Keywords: mycophenolate mofetil; renal; systemic lupus erythematosus; transplantation
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Introduction |
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We report a rare cause of such an association in a renal transplant woman.
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Case |
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In September 2002, she presented with fever associated with arthralgias and watery diarrhoea. Clinical work-up showed a fever of 39.5°C, weight loss of 8 kg over a period of 4 months, a fixed erythematous and papulous rash located in extended areas of the elbows and knees, arthritis of the left knee, and absence of proteinuria or haematuria on STET. Laboratory tests also revealed the following: serum creatinine 72 µmol/l, haemoglobin 12 g/dl, blood leurocytes 3300/mm3, platelets 210 000/mm3, erythrocyte sedimentation rate 26 mm/h and C-reactive protein 10 mg/dl. Liver function tests were normal.
Viral and bacterial serologies were normal. Cytomegalovirus (CMV) serology was as follows IgG 64 mg/l, IgM 8 mg/l, with an increase in the concentration of IgG 15 days later to 128 mg/l and a high replication of CMV, with viraemia at 24 000 copies/ml (by PCR method) suggesting a recent CMV infection. The patient then received ganciclovir at a dose of 700 mg/day over 21 days. This treatment was associated with the disappearance of diarrhoea, arthralgias, fever and CMV replication, but not of leukopenia and skin lesions.
One month later, she was admitted for recurrence of the fever and arthralgias, extension of the skin lesions to the rest of the arms, the feet and the face (over the cheeks), associated with hair loss, pulpitis affecting all the fingers bilaterally and oral ulcers. A lupus band test in the cutaneous lesion area revealed deposits of C3. Immunologic tests showed the presence of ANA with a titre of 1/1600 (by indirect immunofluorescence), and of anti-DNA antibodies with a low concentration of CH50, but a normal concentration of C3 and C4. Histone antibodies and anti-RNP antibodies were not detected.
The association of these symptoms and the positive immunologic tests confirmed the diagnosis of systemic lupus erythematosus (SLE). Therefore, the corticosteroid dosage was increased to 1 mg/kg/day for 2 months, with progressive tapering and azathioprine was replaced by mycophenolate mofetil at a dose of 2 g/day. After a follow-up of 10 months, the outcome was favourable with apyrexia, weight gain and improvement of skin lesions, normalization of white blood cell count, negative serum ANA and normalization of the serum CH50 level.
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Discussion |
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We replaced azathioprine with mycophenolate mofetil because the latter is a T-cell directed immunosuppressive therapy responsible for the inhibition of helper T-cell proliferation and subsequently a decrease in pathogenic DNA antibody production [4].
Conflict of interest statement. None declared.
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References |
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