Infections mimicking difficult-to-treat systemic lupus erythematosus

Infections are closely associated with systemic lupus erythematosus (SLE). SLE patients require aggressive immunosuppression making them vulnerable to unusual or atypical presentations of common infections. They have an inherent immune abnormality predisposing them to infection. On the other hand, infection can act as a trigger for the immune system and lead to a newonset SLE or flare. Here, we present three-patients with SLE and uncommon infection. First case is of a chronic cytomegalovirus-infection that mimicked a 3-year long SLE-disease. Detection of infection and treating it led to withdrawal of all immunosuppressive therapy. There was no further SLE-activity on follow-up. Similarly, in the second case, tuberculosis presented as diffuse lower lobe pneumonitis, which triggered a mild-quiescent undiagnosed SLE (ANA positive with low platelet count) into a full-blown SLE (nephritis and autoimmune hemolytic anemia). Initially, a diagnosis of lupus pneumonitis was made but later complications of cavitation and nonhealing bronchopleural fistula led to a diagnosis of tuberculosis. Again, in this case, treating the infection led to complete resolution of SLE. The third case is of herpes-simplex virus esophagitis that was confused with steroid withdrawal symptoms. It led to a refractory SLE-flare that settled after treatment of infection. Thus, here, we have discussed the complex interplay of these infections with the diagnosis and management of SLE along with an intriguing phenomenon of treating the infection leading to near-cure of an aggressive systemic autoimmune disease.