title: First report of multi-drug resistant tuberculosis in a systemic lupus erythematosus patient.
abstract: BACKGROUND
  Treatment of a multi-drug resistant tuberculosis (MDR-TB) patient is clinically challenging, requiring a minimum of 18 months of therapy. Its occurrence in a systemic lupus erythromatosus (SLE) patient may complicate management of both MDR-TB and SLE. This is the first descriptive report of MDR-TB in an SLE patient.
  
  
  METHODS
  A 19-year old female receiving long-term prednisolone for SLE was diagnosed with MDR-TB. She was started on MDR-TB treatment regimen and prednisolone was replaced with azathioprine. After an initial response to therapy, patient experienced a flare of lupus symptoms. Imaging studies revealed avascular necrosis of right femoral head. She was then treated with intravenous methyl-prednisolone, followed by maintenance corticosteroid. Azathioprine was discontinued due to hematological toxicity and failure to control SLE. Her symptoms of lupus regressed and did not re-occur for the duration of her MDR-TB treatment. Patient was declared cured of MDR-TB after 18 months of ATT. She is currently scheduled for a total hip replacement surgery.
  
  
  CONCLUSIONS
  This case highlights the challenges of simultaneously managing MDR-TB and SLE in a patient due to their over-lapping signs and symptoms, drug-drug interactions, and the need for use of immunomodulatory agents in the absence of standard guidelines and documented previous experiences. Our experience underscores the importance of appropriate selection of treatment regimens for both MDR-TB and SLE.
authors.affiliation: Division of Epidemiology, School of Public Health, University of California, Berkeley, 113 Haviland Hall #7358, Berkeley, CA, 94720-7358, USA. kunchok@berkeley.edu.|The Tibetan Delek Hospital, Dharamshala, Himachal Pradesh, India. kunchok@berkeley.edu.
authors.forename: Kunchok
authors.initials: K
authors.lastname: Dorjee
authors.affiliation: Johns Hopkins University School of Medicine, Baltimore, MD, USA. kdierbe1@jhmi.edu.
authors.forename: Kerry L
authors.initials: KL
authors.lastname: Dierberg
authors.affiliation: The Tibetan Delek Hospital, Dharamshala, Himachal Pradesh, India. sadutshang@yahoo.com.
authors.forename: Tsetan D
authors.initials: TD
authors.lastname: Sadutshang
authors.affiliation: Division of Epidemiology, School of Public Health, University of California, Berkeley, 113 Haviland Hall #7358, Berkeley, CA, 94720-7358, USA. reingold@berkeley.edu.
authors.forename: Arthur L
authors.initials: AL
authors.lastname: Reingold
mesh_terms: D000305:Adrenal Cortex Hormones / Q000627:therapeutic use; D000995:Antitubercular Agents / Q000627:therapeutic use; D001379:Azathioprine / Q000627:therapeutic use; D005260:Female; D005271:Femur Head Necrosis / Q000150:complications; D006801:Humans; D007155:Immunologic Factors / Q000627:therapeutic use; D008180:Lupus Erythematosus, Systemic / Q000150:complications* / Q000188:drug therapy*; D008775:Methylprednisolone / Q000627:therapeutic use; D011239:Prednisolone / Q000627:therapeutic use; D013902:Radiography, Thoracic; D016896:Treatment Outcome; D018088:Tuberculosis, Multidrug-Resistant / Q000150:complications* / Q000188:drug therapy*; D055815:Young Adult
chemical_list: D000305:Adrenal Cortex Hormones; D000995:Antitubercular Agents; D007155:Immunologic Factors; D011239:Prednisolone; D001379:Azathioprine; D008775:Methylprednisolone