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

Abstract

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. Since we could not achieve an improvement of skin lesions after 9 months of belimumab administration on combination with MMF and HCQ, the biologic therapy was switched to another B-cell inhibitor-rituximab (1000 mg intravenously at weeks 0 and 2) known to be used to treat lupus patients. 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. Rituximab turned out to be more efficacious (in combination with MMF and HCQ) for SLE-associated skin lesions in our patient, despite the fact that these drugs are still not approved for treatment of SLE.