A Case of Severe Lupus and Refractory Anemia

Systemic lupus erythematosus (SLE) is a multisystemic connective tissue disease with a wide range of clinical and laboratory manifestations. The diagnosis of SLE is often challenging due to the great variability in its presentation, and treatment should be individualized according to the patient's manifestations and affected organs. We present the clinical case of a 25-year-old female who developed SLE with severe hematological and renal involvement as first manifestations, including hemolytic anemia, thrombocytopenia, and nephrotic syndrome. Diagnosis of SLE was confirmed after positive high titers of ANA and anti-dsDNA antibodies. A kidney biopsy confirmed lupus nephritis class II.  Despite successive treatment with corticosteroids, hydroxychloroquine, intravenous immunoglobulin, and mycophenolate mofetil, there was no hematological improvement, and rituximab was administered, resulting in partial response, with resolution of thrombocytopenia and stabilization of kidney function. However, anemia remained refractory, and subsequent tests indicated a non-hemolytic cause, most likely due to iatrogenic bone marrow suppression. After discontinuing potentially myelotoxic agents, the patient's hemoglobin levels normalized. This case highlights the intricate challenges associated with managing SLE. It underscores the critical importance of ongoing reassessment of therapeutic strategies, particularly in situations where the treatment response is inadequate. This approach enables the optimization of interventions to improve clinical outcomes and address the unique needs of each patient.