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Case Series Very Severe and Refractory Noninfectious Cystitis in Patients with Systemic Lupus Erythematosus: Potential Role of Rituximab Therapy

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Case Series Very Severe and Refractory Noninfectious Cystitis in Patients with Systemic Lupus Erythematosus: Potential Role of Rituximab Therapy Hindawi Case Reports in Rheumatology Volume 2021, Article ID 6610111, 6 pages https://doi.org/10.1155/2021/6610111 Case Series Very Severe and Refractory Noninfectious Cystitis in Patients with Systemic Lupus Erythematosus: Potential Role of Rituximab Therapy Vanessa Ocampo-Piraquive,1 Ine´s Mondrago´n-Lenis,2 Juan G. De los Rios,3 and Carlos A. Cañas 1 1Unit of Rheumatology, Fundaci´on Valle Del Lili, Universidad Icesi, Cali, Colombia 2Department of Internal Medicine, Fundacio´n Valle Del Lili, Universidad Icesi, Cali, Colombia 3Department of Urology, Fundacio´n Valle Del Lili, Universidad Icesi, Cali, Colombia Correspondence should be addressed to Carlos A. Cañas; [email protected] Received 8 November 2020; Revised 2 February 2021; Accepted 24 February 2021; Published 27 February 2021 Academic Editor: Remzi Cevik Copyright © 2021 Vanessa Ocampo-Piraquive et al. -is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Systemic lupus erythematosus (SLE) is a chronic inflammatory autoimmune disease with various clinical manifestations, in- cluding, rarely, a form of interstitial cystitis (lupus cystitis, LC). LC can be asymptomatic and usually has discrete symptoms that improve with conventional therapies available for SLE and/or typical interstitial cystitis. A very severe and refractory form is rarely described. In this study, we present four patients with SLE and a very severe form of noninfectious cystitis refractory to the different forms of treatment described. -e clinical descriptions of the cases, demographic factors, manifestations associated with SLE, and clinical and paraclinical manifestations related to cystitis, treatments, and outcomes are provided. A proposal for the pathogenesis of this condition is based on the common findings of these patients, including the fact that three were in SLE remission and all four receiving rituximab as induction and/or maintenance therapy. 1. Introduction may be the initial presentation of SLE and is predomi- nantly present in women [2, 9]. Systemic lupus erythematosus (SLE) is a chronic in- LC clinically manifests as a variable presence of low flammatory autoimmune disease with various clinical irritative and obstructive urinary symptoms, the most manifestations [1]. One form of interstitial cystitis has common being suprapubic pain, incontinence, polyuria, been described in these patients since the first report by dysuria, and nocturia; urinalysis may reveal leukocyturia Fister GM in 1938 [2] and Shipton in 1965 [3] and finally and/or microscopic haematuria with negative urine cultures characterized and termed “lupus cystitis” (LC) by Orth [4]. It can also be a subclinical condition [4–6]. Symptoms et al. in 1983 [4]. LC is a rare manifestation of SLE, with often overlap or are confused with gastrointestinal symp- an incidence of 0.5–2.3% [5], and descriptions of LC are toms or lower pelvic/gynecologic symptoms, and diagnosis based solely on case reports. -e reported cases come of LC is often delayed. LC can present concomitantly with predominantly from East Asia; the highest incidence has the kidney [8] and/or gastrointestinal involvement of SLE been reported in Korea (2.3% of cases) [6]. In China, [10, 11]. Imaging and urodynamic studies reveal variable incidences of 0.5% and 0.6% [7, 8] have been reported. LC degrees of bladder wall thickening, decreased capacity, 2 Case Reports in Rheumatology urinary tract dilation, and smooth muscle contractibility pain. Urinalysis shows leukocyturia without proteinuria; a [12, 13]. Histologically, leukocyte mononuclear infiltrate, urine culture was negative; a haemogram showed mild haemorrhage, and the variable presence of fibrosis are found; leukopenia; and haemoglobin, normal platelets, C-reactive deposits of immunoglobulins (IgA, IgG, and IgM) and protein (CRP), erythrocyte sedimentation rate (ESR), and complements (C1q and C3) can be identified around the C3 and C4 levels were normal. A cystoscopy was performed small vessel walls of the bladder [14, 15]. Also observed is a that showed urethral narrowing and inflammatory changes variable degree of infiltration by mast cells, which could play in the bladder wall. A bladder biopsy was performed, a pathogenic role [16, 17]. Different therapeutic tools have showing mucosal ulceration, lymphoplasmacytic infiltrate, been useful for disease control, including glucocorticoids and a slight presence of mast cells, without demonstrating [18, 19], antihistamines [9], cyclophosphamide [20], aza- deposits of viral particles in the immunohistochemistry nor thioprine [20], mycophenolate mofetil [10], intravenous deposits of immunoglobulins or complement fractions. immunoglobulin, and plasmapheresis [21]. -is report Treatment was started with fexofenadine, 180 mg day, presents four cases of Colombian patients with SLE and a montelukast, 10 mg day, and amitriptyline, 25 mg day, noninfectious very severe and refractory form of cystitis without improvement. Symptoms worsened further; (VSRC) that showed no response to conventional treat- therefore, intravenous methylprednisolone was initiated at a ments. -e majority of studies are from oriental populations, rate of 500 mg/day for three days and continued at 1 mg/kg and reports are scarce in the Western world. A description is orally. In the absence of a response, azathioprine was added provided of its clinical and therapeutic characteristics and of at 2 mg/kg. Rituximab was discontinued at the onset of possible factors related to this atypical and devastating urinary symptoms. -ere was slow progression towards complication. improvement. Six months later, she continued with anti- histamine, azathioprine, and methylprednisolone, 4 mg 2. Case Report daily, and amitriptyline, 50 mg daily. Dysuria, nocturia, and mild polyuria persisted. Currently, SLE is in remission, and In a cohort of 240 patients with SLE treated since 2007 at the urinalysis showed moderate leukocyturia. Urine cultures for Fundacion´ Valle del Lili, a reference centre for patients in bacteria, mycobacteria, and fungi are consistently negative. southwestern Colombia, 12 (5%) had clinical, laboratory, cystoscopic, or histological manifestations consistent with LC at some points, which improved rapidly with conven- 2.2. Case 2. Case 2 involves a 23-year-old woman with a tional treatment. Of these, four patients developed VSRC, diagnosis of SLE since 14 years of age who initially presented for which the clinical characteristics of the underlying with adynamia, fever, headache, severe polyarthritis, class IV disease, form of presentation, laboratory, imaging, cysto- lupus nephritis, inflamed lung tissue (pleuritis and pneu- scopic, and histological findings, established treatments, and monitis), anaemia, thrombocytopenia, Raynaud’s phe- outcomes are described. nomenon, and ANA titres of 1 :1280, with a homogeneous pattern. Initially, she was treated with high doses of glu- cocorticoids, intravenous cyclophosphamide, 750 mg, with 2.1. Case 1. Case 1 involves a 45-year-old woman with a three intravenous doses every month, and then continued diagnosis of SLE from the age of 40 who initially presented with azathioprine, 2 mg per kg, with which no favourable skin conditions (malar erythema and alopecia areata) and response was observed. -ree months later, mycophenolate then Libman–Sacks endocarditis, polyarthritis, dryness mofetil, 3 g/day, was started, with an adequate initial re- symptoms (xerostomia and xerophthalmia), and hypothy- sponse but a severe relapse nine months later, mainly at the roidism. She showed positivity for several autoantibodies, musculoskeletal and renal levels. It was decided to start including antinuclear antibody (ANA) titres of 1/1280 with a rituximab, 1 g on day 0 and 1 g on day 14, with a very speckled pattern, anti-Sm antibodies, anti-U1 RNP anti- favourable response, and it was decided to continue ritux- bodies, direct Coombs, both IgM and IgG anticardiolipin imab maintenance in a similar cycle every 9–12 months for antibodies, and complement consumption. She initially five years. She required prednisolone for four years, during received glucocorticoids in high doses, which were reduced which the dose could be reduced, and then, the medication until they were discontinued two years later due to disease was discontinued. In the second year of the disease, the remission. A year later, the patient presented disease re- patient developed avascular necrosis in the left femoral head lapsing, and this time, she became refractory to glucocor- that required surgical decompression and then joint re- ticoids, hydroxychloroquine, and azathioprine; therefore, placement. Seven years after the SLE diagnosis and after four mycophenolate mofetil was indicated, without improve- years of clinical and paraclinical remission and monotherapy ment; it was decided to start a rituximab cycle of 1 g on day 0 with rituximab, dysuria, nocturia, polyuria, perineal pain, and 1 g on day 14, with a very favourable response; it was bladder pressure, and vesical tenesmus began. Urinalysis decided to maintain rituximab in a similar cycle every nine showed leukocyturia without proteinuria with a negative months for three years as monotherapy. One year after this urine culture. A haemogram showed mild microcytic treatment, glucocorticoids were discontinued. At 44 years anaemia and normal CRP, ESR, kidney function, and C3 and old, 4 years after the onset
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