Exacerbation of latent lupus: is the culprit acid-fast bacilli or antitubercular therapy?
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CASE BASED REVIEW
Exacerbation of latent lupus: is the culprit acid-fast bacilli or antitubercular therapy? Harpreet Singh & Sucharita Ray & Maneet Kaur & Vikas Gupta & Harish Kumar & Paulomi Talapatra & Rekha Mathur & Suvrat Arya & Naveen Ghangas
Received: 24 January 2013 / Revised: 10 March 2013 / Accepted: 27 March 2013 / Published online: 10 April 2013 # Clinical Rheumatology 2013
Abstract Typical as well as atypical presentations of systemic lupus erythematosus are being increasingly recognized due to improved diagnostic methods. In a tuberculosis-endemic country like India, it was traditionally believed that the occurrence of tuberculosis in lupus was due to the chronic immunosuppression caused by lupus or because of the use of steroids or isoniazid-induced lupus. Increasingly several patients with no recorded predisposition to lupus with a history of treatment for tuberculosis are coming with evidence of systemic lupus erythematosus rather than a drug-limited story. Whether the development of an autoimmune state is a mere conjecture or the presence of acid-fast bacilli in the body for a prolonged duration causes complex antigenic interactions leading to an antigenic response needs to be looked into. We present a report of three such patients and review the pathogenetic interactions H. Singh : V. Gupta : R. Mathur : S. Arya : N. Ghangas Department of Medicine, Pt. B. D Sharma PGIMS, Rohtak, Haryana, India e-mail: [email protected] S. Ray (*) Department of Neurology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India e-mail: [email protected] M. Kaur Department of Medicine, Dayanand Medical College & Hospital, Ludhiana, Punjab, India H. Kumar Department of Pulmonary Medicine and Critical Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India P. Talapatra Department of Rheumatology, Pt. B. D. Sharma PGIMS, Rohtak, Haryana, India
that could possibly explain the role of mycobacterial antigens as a putative antigen in the pathogenesis of lupus. Keywords Epitope spreading . Latent lupus . Lupus . Pathogenesis . Tuberculosis
Introduction With increasing population, attendant overcrowded conditions, and exposure to newer antigens, pesticides, and diseases, systemic lupus erythematosus, once considered a rare disease, not only is being increasingly diagnosed but is showing several atypical presentations and interactions. Tuberculosis is endemic in the country with significant morbidity and mortality rates, and it is not surprising to assume that the two share several complex and hitherto undiscovered interactions, given the propensity for each to lead to a state of profound immunosuppression in the patient. Several reports of active tuberculosis in SLE and the preponderance of miliary and far-advanced pulmonary tuberculosis as well as a higher incidence of extrapulmonary tuberculosis have been reported in the literature. One of the traits of tuberculosis is to establish a prolonged state of latent disease in an immunocompromised patient like lupus. Sever
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