Case report of a lupus patient with a severe flare and miliary tuberculosis: need for proper guidelines for management

Systemic lupus erythematosus (SLE) is an autoimmune disease that is frequently treated with high doses of corticosteroids and other immunosuppressive drugs. Thus patients with SLE are at increased risk for infections with several pathogens including Mycobacterium tuberculosis. There are no established guidelines available for treatment of tuberculosis in SLE patients with high disease activity due to lack of relevant studies and management based more on physician expertise. We report a case of a young SLE patient with high disease activity index (SLEDAI19) as evidenced by the presence of a vasculitic rash, non-healing ulcer on forearm and proteinuria of >1 g/d along with miliary tuberculosis. She was treated with intravenous methylprednisolone pulse up to 3 g and antituberculous therapy, but the result was a fatal outcome. This case report emphasizes the need for formal guidelines for co-management of active tuberculosis and SLE with high disease activity.