Cytomegalovirus reactivation exacerbated thrombocytopenia and haemolysis in a patient with systemic lupus erythematosus.

摘要: To the editor, Immunosuppressive therapy, including high-dose corticosteroids and other immunosuppressive agents, has markedly improved systemic lupus erythematosus (SLE) patient survival. However, these patients are deemed at increased risk for opportunistic infection because of impaired immunity due to therapy. We encountered a with diVuse nephritis complicated severe thrombocytopenia haemolytic anaemia, whose haematological manifestations might have been related cytomegalovirus (CMV) reactivation. A 23-year-old Japanese man was hospitalized urinary abnormalities. Two months prior admission, proteinuria haematuria had detected on routine health examination. On physical Wndings were unremarkable; however, laboratory testing revealed active nephritic sediments marked protein excretion (2.6 g per day), low serum complement [C3 (24 mg/dl) C4 (6 mg/dl)] values, high titre antidouble-stranded DNA (ds-DNA) antibody (63.1 IU/ml; reference range < 20). Renal biopsy mesangial proliferation capillary wall thickening light microscopy, “full-house” pattern immunoXuorescence mesangial/subendothelial electron-dense deposits electron microscopy. During hospitalization, constitutional (i.e., fever general myalgia), arthritis, lymphopenia developed; thus, we diagnosed him SLE associated [International Society Nephrology (ISN), Class IV]. Intravenous methyl prednisolone (0.5 g, three consecutive days) once every 2 weeks oral corticosteroid (prednisolone, 55 mg day) started. This treatment his immunological abnormalities hypocomplementaemia elevated anti-ds-DNA levels); renal function deteriorated creatinine levels around 3.0 mg/dl nephrotic-range proteinuria. 60th hospital day, gross haematuria, petechia, melena, epistaxis suddenly developed. He afebrile, examination unremarkable except bleeding tendency; data (9,000/ l). Peripheral blood smear showed no morphological Coagulation screening results transaminases normal, but haptoglobin level undetectable. Bone marrow aspiration test normal morphology megakaryocytes, an erythroid system, signs haemophagocytosis. Abdominal computed tomography remarkable Platelet-associated IgG (157 ng/10 cells; 5.0–25.0 cells) positive, direct Coombs’ test, anti-granulocyte antibody, anti-cardiolipin-IgM/IgG antibodies, anti2 glycoprotein I cryoglobulin, plasma activity von Willebrand factorcleaving protease (69.5%) negative or results. Evaluation bacterial infection, urine cultures, yielded Anti-parvovirus B 19 IgM Epstein–Barr (EB) virus viremia also negative, peripheral CMV antigenaemia assay equivocal result (5/34,000 leukocytes) [1]. Platelets transfusion symptoms initiated. (1.0 followed by T. Sugimoto (&) · M. Aoyama N. Takeda Sakaguchi Y. Nishio Uzu A. Kashiwagi Department Internal Medicine, Shiga University Medical Science, Seta, Otsu, 520-2192, Japan e-mail: toshiro@belle.shiga-med.ac.jp