Immunotherapies application in active stage of systemic lupus erythematosus in pregnancy: A case report and review of literature

Table 1 The changes of systemic lupus erythematosus in pregnancy of the patients

Time	Preconception	GA 23+ wk	GA 24+ wk	GA 24+ to 28 wk	Postpartum, 7-34 d
Related clinical manifestations and immune related indicators	24-h urine protein fluctuates around 3 g	ALT: 197 U/L; AST: 185 U/L	Hb: 87 g/L	Cr: 176 μmol/L	Hb: 77 g/L
			ALT: 465 U/L; AST: 525 U/L		ALT: 15 U/L; AST: 23 U/L
			Cr: 163 μmol/L		Cr: 79 μmol/L
			24-h urine protein 19.43 g		24-h urine protein 5.81 g
			C3: 0.60 g/L; C4: 0.11 g/L		C3: 0.45 g/L; C4: 0.16 g/L
SLE activity index (score)	4 (proteinuria)	9 (proteinuria, hematuria, fever)	15 (proteinuria, hematuria, cylindruria, fever)		9 (proteinuria, cylindruria, fever)
Immunosuppressant	AZA (dose: 50 mg/d)	AZA (dose: 75 mg/d)	MP injection (dose: 500 mg/d × 3 d, 300 mg/Q12 h × 2 d)	MP injection (dose: 40 mg/d, 80 mg/d × 3 d)	Rituximab 100 mg × 1/2 wk
	MP (dose: 4 mg /d)	MP injection (dose: 500 mg/d × 3 d)	Plasma adsorption therapy	AZA (dose: 75 mg/d)	CYC 200 mg × 2 wk
		IVIg (dose: 20 g /d × 5 d)		HCQ (dose: 200 mg/d)	MP injection (dose: 40 + 30 mg/d × 2 d, 40 + 20 mg/d × 8 d)
				TAC (0.5 mg × 1 d, 0.25 mg × 2 d)
Clinical response		Hb: 93 g/L	Hb: 81 g/L		Hb: 85 g/L
		ALT: 56 U/L; AST: 39 U/L	ALT: 282 U/L; AST: 130 U/L		ALT: 23 U/L; AST: 10 U/L
		Cr: 102 μmol/L	Cr: 136 μmol/L		Cr: 82 μmol/L
		24-h urine protein fluctuates around 19.68 g			24-h urine protein 4.40 g
		C3: 0.52 g/L; C4: 0.10 g/L			C3: 0.68 g/L; C4: 0.18 g/L

ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; AZA: Azathioprine; C3: Complement 3; C4: Complement 4; Cr: Creatinine; CYC: Cyclophosphamide; Hb: Hemoglobin; HCQ: Hydroxychloroquine; sIVIg: Intravenous immunoglobulin; ;MP: Methylprednisolone; SLE: Systemic lupus erythematosus; ; TAC: Tacrolimus .

Table 2 Related clinical manifestations and immune indicators of the patient

Serial		No.	Diagnostic indexes
Clinical manifestation	1		Fever (37.6-40 °C)
	2		Acute cutaneous lupus erythematosus (“butterfly rash”, “discoid Rash”)
	3		Serositis (lung CT images: Serous membrane fluid)
	4		Synovitis (mild joint pain of wrist joint of both hands)
	5		Blood system involvement (leukopenia 2.3 × 109/L, hemolytic anemia 95 g/L, thrombocytopenia 50 × 109/L; ESR 37 mmHg)
	6		Renal system involvement (24-h urine protein 5422.00 mg; RBC under microscope: ++/HP, protein: +2, RBC morphological information: Heterogeneous cell type)
	7		Aphthous ulcers
Immunological indicators	8		ANA level above laboratory reference range (1:1000)
	9		Anti-dsDNA antibodies (+)
	10		Anti-SSA (+)
	11		Anti-Sm antibodies (+)
	12		Antiphospholipid antibodies (IgA 4.21 mg/L, IgG 18.5 g/L)
	13		Low complement (C3: 0.21 g/L, C4: 0.04 g/L)
	14		CD3+CD4+CD28CD4 (37.0%)

ANA: Antinuclear antibodies; CT: Computed tomography; ESR: Erythrocyte sedimentation rate; RBC: Red blood cell.