Longitudinal Immunophenotypic Changes in Refractory Lupus Nephritis After B-cell Depletion: A 25-year Case Study.
Chung-Che Chen, Jeng-Wei Lu, Yi-Jung Ho et al.
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Case in brief
A woman diagnosed with systemic lupus erythematosus at age 25 developed biopsy-proven class IV lupus nephritis and entered a 20-year clinical remission after 12 cycles of intravenous cyclophosphamide. In December 2025, she presented with a severe refractory renal flare; repeat biopsy showed mixed class IV+V nephritis. She received pulse steroids and rituximab, then developed Salmonella bacteremia and cytomegalovirus viremia with acute kidney injury. Targeted antibiotics and valganciclovir resolved the infections while lupus nephritis remained controlled.
What made this case unusual
The case documents a severe renal flare after a 20-year remission, followed by both Salmonella bacteremia and CMV viremia with acute kidney injury after rituximab.
Diagnostic / clinical pearl
In a refractory lupus nephritis flare, repeat renal biopsy can identify a changed histologic class; after intensive B-cell depletion, new kidney injury may also accompany serious infections.
Why it matters
The case illustrates the challenge of controlling refractory nephritis while recognizing and treating opportunistic infections in long-standing SLE.