Disseminated tuberculosis with macrophage activation syndrome in a child with lupus nephritis

In children with systemic lupus erythematosus on immunosuppressive therapy, infection is a known complication. We present a case of a 12-year-old girl who was previously diagnosed with lupus nephritis but had stopped taking allopathic medications and had been on herbal medicines for a year. She was referred to us with persistent fever and disease activity in spite of restarting immunosuppressive treatment. Results of blood tests and bone marrow aspiration were suggestive of macrophage activation syndrome. Imaging of her chest and abdomen showed features suggestive of miliary tuberculosis (TB) in the lungs and granulomas in the spleen. Mycobacterium tuberculosis was identified in bone marrow cultures, resulting in a diagnosis of disseminated TB. She was successfully treated with intravenous steroids, anti-tuberculous therapy and intravenous immunoglobulin. Mycophenolate mofetil was added after 6 weeks. The patient recovered from TB and her lupus was under control during follow-up.