J Rheum Dis 2019; 26(4): 273-277  
Severe Hypogammaglobulinemia Associated with Active Lupus Nephritis Treatment Resulting in Cytomegalovirus Infection
Min Kyung Chung, Yeunmi Kang, Jisoo Lee
Division of Rheumatology, Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
Correspondence to: Jisoo Lee http://orcid.org/0000-0001-6279-7025
Division of Rheumatology, Department of Internal Medicine, Ewha Womans University School of Medicine, 1071 Anyangchoen-ro, Yangcheon-gu, Seoul 07985, Korea. E-mail : leejisoo@ewha.ac.kr
Received: May 3, 2019; Revised: August 1, 2019; Accepted: August 3, 2019; Published online: October 1, 2019.
© Korean College of Rheumatology. All rights reserved.

This is a open Access article, which permits unrestricted non-commerical use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Patients with severe active lupus nephritis (LN) require immunosuppressive therapy to induce remission. However, the development of profound hypogammaglobulinemia causing cytomegalovirus (CMV) disease is a rare occurrence during standard immunotherapy. A 27-year-old woman who presented with active LN along with moderate renal impairment was treated with of mycophenolate mofetil (MMF) and methylprednisolone. MMF was soon switched with low-dose intravenous (IV) cyclophosphamide (CYC) owing to the development of posterior reversible encephalopathy syndrome and deterioration of renal function requiring hemodialysis. After two cycles of IV CYC, she developed CMV colitis and pneumonia. Although her serum immunoglobulin (Ig) concentrations before receiving immunosuppressive treatment were normal, they were profoundly reduced at CMV disease onset and continued to maintain low level for 30 months. Severe hypogammaglobulinemia can occur during standard therapy for LN, especially in patients with impaired renal function, pointing out the importance of close monitoring of Ig levels and CMV infection.
Keywords: Lupus nephritis, Hypogammaglobulinemia, Cytomegalovirus infection


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