Background: Systemic lupus erythematosus is a multisystem autoimmune disease with variable manifestations, dysregulated type I interferon responses, and defective immune tolerance mechanisms. SLE, multidrug-resistant tuberculosis (MDR-TB), and coronavirus disease 2019 infection may be a rare, complex combination presenting a significant challenge in screening, management, and infection control.

Case: A 24-year-old female diagnosed with SLE nephritis maintained on mycophenolate, mofetil, and hydroxychloroquine developed disseminated multidrug-resistant tuberculosis (MDR-TB) involving the lungs, liver, and lymph nodes. She was started on an anti-TB regimen. However, QT prolongation and heart failure was noted, thus discontinuation of HCQ. On the 10th month of treatment with clofazimine, cycloserine, p-aminosalicylic acid, and delamanid, she developed fever, dyspnea, chest pain, and disorientation accompanied by progressive oxygen desaturation. A nasopharyngeal swab for SARS-CoV-2 RT-PCR was positive, and a high-resolution chest CT showed new peripheral ground-glass opacities consistent with COVID-19 pneumonia. Oxygen support with a high-flow nasal cannula at 60% FiO2, low molecular weight heparin, meropenem, remdesivir, and dexamethasone were given; MDR-TB treatment was temporarily withheld. The patient recovered after 3 weeks of hospitalization, and MDR-TB treatment was resumed following hospital discharge.

Conclusion: This case illustrates the challenges in healthcare access brought about by the pandemic and the management of drug-to-drug interactions in the different treatment regimens for lupus nephritis, disseminated MDRTB, and severe COVID-19 infection.

Keywords: severe covid-19 infection, lupus nephritis, multi-drug resistant tuberculosis, management challenge

1. Sriram Krishnamurthy and Subramanian Mahadevan. Systemic Lupus Erythematosus: Recent Concepts in Genomics, Pathogenetic Mechanisms, and Therapies, International Scholarly Research Network ISRN Immunology Volume 2011, Article ID 868964, 7 pages doi:10.5402/2011/868964
2. Megan R. W. Barber, et. Al. Global epidemiology of systemic lupus erythematosus. Nature Reviews Rheumatology . August 2021
3. Kene Ebuka Maduemem ,Comfort O. Adedokun, and Adela Vatca. Combined Diagnosis of Systemic Lupus Erythematosus and Tuberculosis in an Irish Adolescent Female . Hindawi Case Reports in Pediatrics. Volume 2018, Article ID 2031219 https://doi.org/10.1155/2018/2031219
4. Gustavo Guimara ̃es Moreira Balbi, Francinne Machado-Ribeiro, Cla ́udia D.L. Marques, Fla ́vio Signorelli, and Roger Abramino Levy. The interplay between tuberculosis and systemic lupus erythematosus. Curr Opin Rheumatol 2018
5. Kunchok Dorjee, Kerry L Dierberg, Tsetan D Sadutshang and Arthur L Reingold. First report of multidrug resistant tuberculosis in a systemic lupus erythematosus patient. BMC Res Notes (2015) 8:337 DOI 10.1186/s13104-015-1302-x
6. Ruth Fernandez-Ruiz, Jacqueline L. Paredes, and Timothy B. Niewold. COVID-19 in patients with systemic lupus erythematosus: lessons learned from the inflammatory disease. 2020 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.trsl.2020.12.007
7. Prabu VNN, Agrawal S. Systemic lupus erythematosus and tuberculosis: A review of complex interactions of complicated diseases. J Postgrad Med July2010 Vol 56 Issue 3
8. Katsuyama E, Suarez-Fueyo A, Bradley SJ, et al. The CD38/ NAD/SIRTUIN1/EZH2 axis mitigates cytotoxic CD8 T cell function and identifies patients with SLE prone to infections. Cell Rep 2020;30:112–123.e4. https://doi.org/10.1016/j.cel- rep.2019.12.014.
9. Barber C, Gold WL, Fortin PR. Infections in the lupus patient: perspectives on prevention. Curr Opin Rheumatol. 2011;23:358–65.
10. Enberg G, Kahn C, Goity F, Villalón S, Zamorano R, Figueroa E. Infections in patients with systemic lupus erythematosus. Rev Med Chil. 2009;137:1367–74.
11. Victorio-Navarra ST, Dy EE, Arroyo CG, Torralba TP. Tuberculosis among Filipino patients with systemic lupus erythematosus. Semin Arthritis and Rheum. 1996;26:628–34.
12. Doria A, Canova M, Tonon M et al. Infections as triggers and complications of systemic lupus erythematosus. Autoimmune Rev 2008; 8: 24-8.
13. RouzierV,LiautaudB,DeschampsMM,2020.Facingthemonster in Haiti. N Engl JMed 383: e4.
14. Bourgonje AR, Abdulle AE, Timens W, et al. Angiotensin-con- verting enzyme 2 (ACE2), SARS-CoV-2 and the pathophysiol- ogy of coronavirus disease 2019 (COVID-19). J Pathol 2020;251:228–48. https://doi.org/10.1002/path.5471.
15. Skendros P, Mitsios A, Chrysanthopoulou A, et al. Comple- ment and tissue factor-enriched neutrophil extracellular traps are key drivers in COVID-19 immunothrombosis. J Clin Invest 2020. https://doi.org/10.1172/jci141374.
16. Dheda K et al., 2017. The epidemiology, pathogenesis, trans- mission, diagnosis, and management of multidrug-resistant, extensively drug-resistant, and incurable tuberculosis. Lancet Respir Med 2017 Mar 15: S2213-2600(17)30079-6.
17. Stalz Charles Vilbrun, Laurent Mathurin, Jean W. Pape, Daniel Fitzgerald, and Kathleen F. Walsh. Case Report: Multidrug-Resistant Tuberculosis and COVID-19 Coinfection in Port-au-Prince, Haiti. Am. J. Trop. Med. Hyg., 103(5), 2020, pp. 198–1988 doi:10.4269/ajtmh.20-0851
18. Raghavan S, Gonakoti S, Asemota IR, Mba B. A case of sys- temic lupus erythematosus flare triggered by severe coronavirus disease 2019. J Clin Rheumatol 2020;26:234–5. https://doi.org/ 10.1097/rhu.0000000000001531.
19. Hayden A, Vyas-Lahar A, Rella V, Rudinskaya A. Severe refrac- tory thrombocytopenia in a woman positive for coronavirus dis- ease 2019 with lupus and antiphospholipid syndrome. Lupus 2020;29:1472–4. https://doi.org/10.1177/0961203320940389.
20. Tsokos GC. Systemic lupus erythematosus. N Engl J Med 2011;365:2110–21. https://doi.org/10.1056/NEJMra1100359.