A CASE OF LUPUS ENCEPHALOPATHY COMPLIATED WITH TUBERCULOUS MENINGITIS TREATED WITH TELITACICEPT

 Systemic lupus erythematosus (SLE), an autoimmune disease, is highly heterogeneous and involves multiple systems, commonly affecting various organs such as the skin, joints, kidneys, hematological system, and nervous system. Among them, neuropsychiatric systemic lupus erythematosus (NPSLE), as a severe neurological complication of SLE, often manifests as cognitive impairment, epileptic seizures, and psychiatric symptoms, posing a high risk of death. Tuberculosis infection is a significant global public health issue. Among patients with SLE receiving immunosuppressive therapy, the incidence of tuberculosis infection shows a remarkable upward trend. Of particular concern is tuberculous meningitis. Not only is it extremely life - threatening and progresses at a very rapid pace, but also its neurological symptoms partially overlap with those of NPSLE in clinical manifestations. Therefore, when NPSLE patients are complicated with tuberculous meningitis, the contradictions and challenges in treatment are particularly prominent. For patients with NPSLE complicated with tuberculous meningitis, formulating a treatment plan requires finding a delicate balance between anti - tuberculosis treatment and immunosuppressive therapy. Currently, there is a lack of unified standard guidelines for the treatment of NPSLE complicated with tuberculous meningitis both at home and abroad. The formulation of treatment plans mostly depends on doctors' clinical experience and the specific conditions of patients, which limits the improvement of treatment efficacy to some extent. However, with the wide application of biological agents in the treatment of autoimmune diseases, how to rationally use biological agents in this special patient population has become an urgent clinical problem to be solved.Telitacicept targets two key cytokines, BLyS and APRIL, and precisely regulates B - cell activation, thereby effectively inhibiting the autoimmune response in SLE. It has shown good efficacy and safety in the treatment of SLE. Moreover, Telitacicept has no significant interference with T - cell - mediated cellular immunity, which is crucial for anti - tuberculosis treatment. Therefore, for SLE patients complicated with tuberculous meningitis, the application of Telitacicept may provide a new treatment strategy, which can effectively control the condition of SLE without significantly increasing the risk of tuberculosis infection. Therefore, exploring the application of Telitacicept in this special patient population is of great significance. This case report presents a complex case of NPSLE complicated with tuberculous meningitis treated with Telitacicept in combination therapy, providing a reference for clinical practice.

A 50 - year - old female patient had a history of SLE and lupus nephritis type IV. She had previously received immunosuppressive therapy but later discontinued the medication on her own. In May 2025, the patient presented with fatigue, muscle soreness, and joint pain. Laboratory tests revealed ANA (+) with a nuclear granular pattern at a titer of 1:320, weakly positive anti - dsDNA; complement C3 was 0.8 g/L, complement C4 was 0.32 g/L, 24 - hour urinary protein was 11.84 g, white blood cell count was 2.5×10⁹/L, hemoglobin was 100 g/L, platelet count was 76×10⁹/L, serum creatinine was 150 μmol/L, serum albumin was 24 g/L, and the SLEDAI score was 14. She was treated with a combination of corticosteroids and tacrolimus. In July 2025, the patient developed fever accompanied by abdominal pain. Abdominal CT showed an abscess in the right psoas major muscle. Tubercle bacilli were detected in the pus aspirated from the abscess, and the diagnosis of "tuberculous abscess of the right psoas major muscle" was considered. Tacrolimus was discontinued, and the dosage of corticosteroids was gradually reduced. Anti - tuberculosis treatment with "isoniazid, rifampicin, pyrazinamide, and ethambutol" was initiated. During the treatment, the patient still had recurrent fever, along with seizures and transient loss of consciousness. Next - generation sequencing (NGS) of cerebrospinal fluid detected Mycobacterium tuberculosis, and the diagnosis of "tuberculous meningitis" was made. The treatment regimen was adjusted to "isoniazid, rifabutin, pyrazinamide, ethambutol, and clofazimine" for intensive anti - tuberculosis treatment. However, the patient still had persistent low - grade fever during the course of the disease.In June 2025, the patient had another episode of seizures accompanied by transient loss of consciousness. Electroencephalogram (EEG) showed a mildly abnormal EEG, and cranial MRI revealed multiple abnormal signals in the brain parenchyma without obvious enhancement of the meninges. Imaging findings suggested the possibility of lupus encephalopathy. Considering the patient's recurrent neurological symptoms despite regular intensive anti - tuberculosis treatment, as well as the results of EEG and cranial MRI, and referring to the Barada diagnostic criteria for lupus encephalopathy, the final diagnosis of "lupus encephalopathy and tuberculous meningitis co - existing" was made. According to the 2023 version of the European League Against Rheumatism (EULAR) guidelines, corticosteroid pulse therapy is recommended for moderate - to - severe NPSLE (such as epilepsy, psychosis, and coma). The 2019 Chinese guidelines for the diagnosis and treatment of central nervous system tuberculosis recommend the use of corticosteroids in tuberculous meningitis to reduce the inflammatory response, lower intracranial pressure, and improve prognosis. Therefore, on the basis of continuing intensive anti - tuberculosis treatment,methylprednisolone 0.5 g was given for pulse therapy for 3 days, followed by an adjustment to methylprednisolone 40 mg once daily in combination with Telitacicept 160 mg once weekly. After using methylprednisolone 40 mg for 1 month, the dosage was reduced by one tablet per week.Efficacy was evaluated before treatment and 8 weeks after treatment. The evaluation indicators included blood routine (white blood cells, hemoglobin, platelets), 24 - hour urinary protein quantification, liver and kidney function (serum creatinine, serum albumin), complement (complement C3, complement C4), cranial imaging examinations, and cerebrospinal fluid NGS. 

After treatment, the patient's condition improved rapidly, and there were no more symptoms of fever and seizures. After collecting the data 8 weeks after treatment, it was found that all the indicators had improved significantly. The 24 - hour urinary protein quantification decreased from 11.84 g to 0.34 g. The white blood cell count, hemoglobin level, and platelet count returned to the normal range. The complement levels also returned to normal. The serum creatinine level decreased from 150 μmol/L to 110 μmol/L, and the serum albumin level increased from 24 g/L to 41 g/L. Cranial MRI showed that the multiple abnormal signals in the brain parenchyma were significantly reduced and absorbed. Re - examination of cerebrospinal fluid NGS did not detect Mycobacterium tuberculosis. 

In the complex cases of lupus encephalopathy complicated by tuberculous meningitis, Telitacicept demonstrates significant therapeutic advantages and important application value. Traditional immunosuppressive therapy faces a dilemma when SLE activity coexists with tuberculosis infection. However, Telitacicept precisely regulates B - cell activation through dual - targets, effectively suppressing the autoimmune response in SLE without significantly increasing the risk of tuberculosis infection. In this case, Telitacicept facilitated the rapid and safe reduction of corticosteroid dosage, reducing the side - effects of corticosteroids. As a result, both the SLE condition and tuberculosis infection were effectively controlled, achieving a dynamic balance between immunosuppressive therapy and anti - tuberculosis treatment. This case can provide a reference for similar clinical cases. In the future, more large - scale, multi - center clinical studies are needed to comprehensively evaluate its long - term efficacy and safety, providing a basis for its widespread application.