Belimumab in refractory systemic lupus erythematosus pleural effusion

Torrente-Segarra, Vicenç; Bonet, Maria

doi:10.1016/j.medcli.2020.12.036

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This research group have published satisfactory treatment response to belimumab for refractory pericarditis<a class="elsevierStyleCrossRef" href="#bib0025">1</a> and pleuritis<a class="elsevierStyleCrossRef" href="#bib0030">2</a> in SLE who fulfilled 1982 American College of Rheumatology criteria for SLE.<a class="elsevierStyleCrossRef" href="#bib0035">3</a> Mainly, SLE patients who develop refractory serositis may show short or long-standing SLE course. Several immunosuppressants (methotrexate, hydroxychloroquine, leflunomide along with low-medium prednisone dosage; and aspirin for the pericarditis SLE patient) were prescribed to control other than serositis symptoms. Since majority of these SLE features are frequent and mild, though, the need to control patients’ serositis symptoms, short of breath and serositis severity (massive pleuritis) made the authors try belimumab in order to control disease activity. Despite patients had previously failed to control disease activity through several treatments, belimumab showed both rapid efficacy and safety. Within a span of 6 months, both patients showed significant clinical improvement with no SLE flares and prednisone dosage was lowered. Altohugh several trials of belimumab have been performed in SLE, there is no specific data in serositis outcome, nor even in clinical practice.<a class="elsevierStyleCrossRef" href="#bib0040">4</a>We present a 29-year old woman with stablished SLE diagnosed in April 2018 with following ACR SLE criteria: malar rash, oral ulcers, photosensitivity, positive antinuclear antibodies (ANA) (1/640 titer) and anti-dsDNA antibodies testing. The patient also showed Raynaud's phenomenon hypocomplementaemia, positive RNP and Sm antibodies testing and polyarthralgia and fatigue. Initially, the patient responded to low-dose prednisone and hydroxychloroquine therapy. Patient also suffered from mild allergic asthma. In September 2019 the patient showed short of breath, chest pain, non-productive cough and a massive left pleuritis in the X-ray testing with an exudative pleural effusion evidence after performing diagnostic thoracocentesis. After common respiratory and systemic infections and malignant, metabolic, cardiac and renal conditions were ruled out, patient initiated high-prednisone dosage and mycophenolate mophetil 720mg daily, alongside hydroxychloroquine. Despite observing a moderate response after eight months of treatment, a moderate right pleuritis image in the routinely X-ray testing was demonstrated, higher anti-dsDNA level and worse hypocomplementaemia were present. Therefore, we considered mycophenolate mophetil as insufficient to control SLE activity (SLEDAI=8) and subcutaneous belimumab was started. Since belimumab was initiated, the patient showed slow but evident improvement (negativization of anti-dsDNA levels, normalization of complement levels, significant X-ray and clinical improvement), allowing to reduce prednisone to 5mg daily and stop mycophenolate mophetil treatment within six months.To the best of our knowledge, the case we present is the second pleuritis SLE patient who show positive outcome during belimumab treatment, and the third suffering serositis (pleuritis and/or pericarditis) as well. In our case, a bilateral involvement was seen after intensive immunosuppressant and prednisone therapy. The latter highlights the need to control the underlying disease as, despite receiving intensive immunosuppressant treatment, the patient showed worsening of her pulmonary SLE involvement and evidence of serological SLE flare. Belimumab offered an alternative to better control disease in our case and we suggest including ‘serositis’ to the spectrum of SLE treatable features with belilmumab when other more well-known immunosuppressants fail to control SLE activity.Conflict of interestThe authors do not have conflict of interest for this study." 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Rothfield" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Arthritis Rheum" "fecha" => "1982" "volumen" => "25" "paginaInicial" => "1271" "paginaFinal" => "1277" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0040" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Response to belimumab among patients with systemic lupus erythematosus in clinical practice settings: 24-month results from the OBSErve study in the USA" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C.E. Collins" 1 => "M. Dall’Era" 2 => "H. Kan" 3 => "C. Macahilig" 4 => "C. Molta" 5 => "V. Koscielny" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/lupus-2015-000118" "Revista" => array:5 [ "tituloSerie" => "Lupus Sci Med" "fecha" => "2016" "volumen" => "3" "paginaInicial" => "e000118" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26835146" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/00257753/0000015800000001/v2_202201010646/S0025775321000853/v2_202201010646/en/main.assets" "Apartado" => array:4 [ "identificador" => "66430" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Cartas al Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/00257753/0000015800000001/v2_202201010646/S0025775321000853/v2_202201010646/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775321000853?idApp=UINPBA00004N"]

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