1. Patients with systemic lupus erythematosus (SLE) are at higher risk for tuberculosis (TB) infection due to immune deficiencies caused by the disease and corticosteroid treatments like methylprednisolone (MP). 2. Anti-TB treatments can cause adverse events like hepatitis in SLE patients, increasing their risk of disease flares. The patient presented experienced anti-TB induced hepatitis and possible SLE flare. 3. It can be difficult to distinguish SLE flares from infections in these patients. While infections often increase CRP and procalcitonin, SLE flares feature increased proteinuria, fever, and SLEDAI scores. The presented patient's labs and symptoms suggested an infection

1. Acute Pulmonary Tuberculosis in
Systemic Lupus Erythematosus

2. Case-based Discussion & Book Reading
Presented : dr. Khoirul Anwar
Supervisor : dr. Ayu P., Sp. PD KR

3. INTRODUCTION....

4. Infection,
44%
SLE flare, 24%
Others, 18%
Surgical Cause,
14%
Penyebab Rehospitalisasi
Infection SLE flare Others Surgical Cause
Infection in SLE

5. • active SLE
• nephritis,
• Sepsis
• and cardiovascular disease
Mortality in SLE

6. • Prevalence ± 5%
• Pulmonary TB > extra pulmonary
Tuberculosis in SLE

7. THE CASE....

8. Wanita, 32 tahun penderita SLE dengan keluhan
utama saat ini lemas dan sesak
1 2 3 4
Kontrol rutin di poli
dengan tx Sandimmun
2x100mg dan MP tape
dose
Juli 2016 mondok kembali
karena AIHA (hb 6,2)  BLPL
dengan tx pulang MP 8mg 3-
2-0 dan sandimun 2x100mg
Kontrol di poli dengan Tx
sandimmun 2x50mg dan
novorapid
Okt 2013 tegak SLE (AIHA,
efusi pericard, oral ulcer,
anti dSDNA (+), LE sel (-)
 Tx MP dan sandimmun
1 minggu
sariawan
memberat
dan batuk,
makan dan
minum ⬇,
lemas (+)

9. RPS :
Sejak 1 minggu os mengalami lemas, batuk dan sesak yang semakin memberat. Sariawan
berupa bercak putih di lidah (+), sulit makan (+), demam (+), batuk dahak (+), darah (-), kejang
(-), pingsan (-), nyeri sendi memberrat (+), kaki lemas (+)
Os menyangkal batuk lama, ⬇ BB, keringat malam, maupun kontak TB

10. Pemeriksaan Fisik
KU : sedang, CM, gizi baik
TB 150 cm, BB 40 kg, IMT 21,22kg/m²
VS : TD 110/70 mmHg, tidur, manset di lengan kanan, large adult cuff
N 116 x/menit, irama teratur, isi dan tekanan cukup
R 29 x/menit, irama teratur, tipe pernapasan thorakoabdominal
T° 38 °C, suhu aksila
Kepala : Insp. : konj. pucat (-), sklera ikterik (-), kulit tipis (+), hirsutisme (+), moon
face (+), oral trush (+), oral ulcer (+),
Palp. : tidak ada nyeri tekan, tak teraba massa
Leher : Insp. : JVP tak meningkat, buffalo hump (+),
Palp. : lnn ttb
Thorax :
Pulmo: Insp. : simetris, KG (-), retraksi (-)
Palp. : stem fremitus kanan = kiri
Perk. : sonor (+)
Ausk.: vesikuler (+) RBK (+/+) RBB (-) Wheezing (-)
Cor : Insp. : IC tak tampak
Palp. : IC teraba di SIC V LMCS
Perk. : kardiomegali (-), kesan konfigurasi dbn
Ausk. : S1-2 murni reguler, bising (-)

11. Pemeriksaan Fisik
Abdomen : Insp. : rounded
Ausk.: peristaltik (+) N
Perk. : timpani di seluruh regio
Palp. : NT (+) regio epigastrium, H/L ttb
Extremitas : Insp. : edema − − raynaud phenomen +/+
− −
Palp. : akral hangat, tidak ada nyeri tekan

12. Ro thorax 07/10/16 :
• Round pneumonia segmen
anterior lobus superior dekstra
• cardiomegali

13. PEMERIKSAAN PENUNJANG
Darah Rutin 7/10/16 14/10/16 19/10/1
6
21/10/16
Hemoglobin 12,2 11,3 8,9 12,8 g/dL
Angka Leukosit 15,06 19,8 9,2 16 /mL
Segmen 97,1 94,4 87,8 89 %
Limfosit 1 5,1 7,3 %
Monosit 1,3 1,8 4,6 %
Eosinofil 0,1 0,1 0,2 %
Basofil 0,1 0,2 0,2 %
Angka Trombosit 362 238 185 186 /mL
Angka Eritrosit 3,9 3,6 2,9 /mL
Hematokrit 38,9 32,9 25,5 %
MCV 99,6 90,6 86 fL
MCH 31,2 30,1 30 Pg

14. PEMERIKSAAN PENUNJANG
7/10/16 14/10/16 19/10/16 21/10/1
6
BUN 62 21 15
Creat 2,4 0,9 0.6
AU
Na 133 140 148 148
K 4,4 2,6 2,13 3,5
Cl 98 101 103 107
SGOT 10 16 602
SGPT 17 15 168
TP
Alb 2,5 2,8 3,2
GDS 527
HbsAg (-)

15. PEMERIKSAAN PENUNJANG
ANA (+)
dSDNA (+)
Coomb test (+)
C3
C4
CD4 7
Anti HIV (-)
Tbil 0,8 5,6
DBil 0,2 4,5
16/10 19/10
CRP
Procalc 2,4 0,9

16. PEMERIKSAAN PENUNJANG
7/10
pH 6,0
BJ 1,010
Protein (-)
Glukosa +4
Bilirubin (-)
Urobilin (-)
Keton (-)
Nitrit (-)
Eritrosit 5
Silinder (-)
Silinder
patologis
(-)
Bakteri 330
LE (-)

17. Sputum
• Cat gram = (-)
• BTA 3 kali (-)
• K/S tidak tumbuh
Darah
• K/S tidak tumbuh
Urine
• BTA (-)
• K/S tidak tumbuh

18. EKG07/10/16 : Sinus Rythm, heart rate 100 kali/menit

19. SLEDAI 7/10 19/10
Gangguan neuro (-) 8
Gangguan ginjal (-) (-)
Vaskulitis (-) 8
Hemolisis (-) (-)
Trombositopnia (-) (-)
Myositis (-) (-)
Artitis (-) (-)
Mukokutan 2 2
Serositis 2 2
Demam 1 1
Fatigue 1 1
Leukopenia (-) (-)
TOTAL 6 22

20. Re-assesment
1. Sistemik lupus eritematosus dengan manifestasi
• Chronic kidney disease stage IV et causa nefritis lupus
• Suspek community acquired pnemumoniae dd pneumonitis dd TB paru
• Mukokutan (oral ulcer) dengan candidiasis oral
• Riwayat efusi paricard moderate tanpa tamponade
2. Hiperglikemia stress pada diabetes mellitus tipe lain
3. Hipoalbuminemia
4. Hiponatremia normoosmolar

21. Terapi :
• Diet cair / lunak
• Sandimun 2x50 mg
• MP 16-16-0
• Inj. Novomix 6-6-6
• Nystatin drop 4x1 cc
• Tranfusi albumin 20% 100 cc
• Inj. Ampisulbac 1,5 gram/12 jam
• Azitromicin 500mg/24 jam
• Fluconazole 800mg/24 jam 
400mg/24 jam  200mg/24 jam
Plan :
• Cukupi kebutuhan cairan 30-
50cc/kgbb/24 jam
• Monitor UOP 0,5-
1cc/kgbb/jam
• Rontgen thoraks serial
• Tranfusi albumin s/d ≥3
• Oksigenasi NK 3lpm
• Cek gene ekspert
• BTA urin
• USG thoraks hari senin
• Ks jamur
• Ks darah

22. Evaluasi klinis paru
• Terjadi efek samping
OAT (hepatitis)
• Terjadi Flare ? (NPSLE
?)
• MP 750mg/24jam
• Gambaran
pneumonia menetap
• Mulai 4FDC
• Gambaran pneumonia
(5 hari batuk, sesak,
demam)
• Tx empirik
• MP 62,5mg/24 jam
• Sandimmun 2x50mg

23. DISCUSSION....

24. Points Of Discussion
• TB infection risk in SLE:
mechanism and susceptibility
factors
• Anti TB and its adverse events
in SLE
• Treatment SLE flare (MP) in TB
infection
Problems...

25. Points Of Discussion
• TB infection risk in SLE:
mechanism and susceptibility
factors
• Anti TB and its adverse events
in SLE
• Treatment SLE flare (MP) in TB
infection
Problems...

26. • Prevalence ± 5%
• Pulmonary TB > extra pulmonary
Tuberculosis in SLE

27. TB in SLE
Lingkaran setan hubungan infeksi dengan autoimunitas (SLE)

28. Immunodeficiency in SLE

29. Immunodeficiency in SLE

30. Immune respone in TB
Melibatkan sel T (CD4 CD8), sitokin, sel B, complemen

31. Complement in TB
C3-dependent entry pathway
into resident alveolar macrophages

32. Complement in TB
Role Complement in TB
C3-dependent entry pathway
into resident alveolar macrophages

33. Problems... (1)
SLE Complement
deficiency
Risk for TB
infection
SLE is Risk factor for TB infection
Pada Pasien ini
• Penderita SLE sejak 2013
• CD4 = 7 (⬇)
• Kadar complement rendah

34. Points Of Discussion
• TB infection risk in SLE:
mechanism and susceptibility
factors
• Anti TB and its adverse events
in SLE
• Treatment SLE flare (MP) in TB
infection
Problems...

35. Corticosteroid... Immune def.
• Genomic action
• Non genomic action

36. Corticosteroid... Immune def.
• Genomic action
• Low dose
• Long periode

37. Corticosteroid, TB risk...

38. Corticosteroid, TB risk...

39. Problems... (1)
SLE Complement
deficiency Risk for TB
infection
• SLE is Risk factor for TB
infection
• Corticosteroid (longterm) is risk
factor for TB
Pada Pasien ini
• Penderita SLE sejak 2013
• CD = 7 (⬇)
• Kadar complement rendah
• Penggunaan jangka panjang MP
Corticosteroid
treatment

40. TB in SLE
Rontgen thorax :
• Milier
• Konsolidasi diffuse
• TB klasik (konsolidasi apex)
Pada Pasien ini
Round pneumonia segmen anterior lobus superior
dekstra

41. TB in SLE

42. TB in SLE
Perjalanan penyakit TB pada SLE:
• Akut
• progresif
Pada Pasien ini
• Gejala akut
• progresif

43. Points Of Discussion
• TB infection risk in SLE:
mechanism and susceptibility
factors
1. SLE dan MP jangka panjang 
resiko TB
2. TB pada SLE dapat bersifat
akut dengan gambaran klinis
dan radiologis tidak khas
Problems...

44. Points Of Discussion
• TB infection risk in SLE:
mechanism and susceptibility
factors
• Anti TB and its adverse events
in SLE
• Treatment SLE flare (MP) in TB
infection
Problems...

45. Anti TB Tx is the Key
• Improve clinicaly and
radiographic
• Worsening
• PCR TB (+)
• M. Tb micros (+)
• Culture (-)
• Start anti TB tx
• 5 days caugh
• Dyspnue
• Fever
• Antibiotic empiric 
escalation on
antibiotic

46. Anti TB Tx is the Key
• Drug-induced
Hepatitis
• Encephalopaty dd
NPSLE
• Clinically Worsening
• PCR TB  tdk
dikerjakan
• M. Tb micros  (-)
• Culture  (-)
• Start anti TB tx
• 5 days caugh
• Dyspnue
• Fever
• Antibiotic empiric 
escalation on
antibiotic
PADA PASIEN INI.....

47. Anti TB induce hepatitis SLE as a risk??
In Facts
• Pasien mengalami OAT-induce
hepatitis
• Klinis berat hingga
encepalopati
• Apakah SLE mempengaruhi
kejadian ini?
• Apakah OAT-induce hepatitis
menyebabkan flare ?

48. Drug induce hepatitis

49. Pirazinamide in liver

50. SLE pathophysiology

51. SLE in drug induced hepatitis
Tissue inflamation and necrosis
(liver injury)

52. SLE in drug induced hepatitis
EVIDENCE...??
• Incidence 12,9% overall
• SLE increase risk for Anti
TB liver injury

53. SLE in drug induced hepatitis
EVIDENCE...??
• 237 pts SLE  3 pts TB
• 3 pts TB  Anti TB liver
injury
• SLE ⬆ risk anti TB liver
injury

54. Points Of Discussion
• Anti TB and its adverse events
in SLE
1. Early diagnosis and Tx is key
point
2. SLE ⬆ risk for anti TB liver
injury
3. Anti TB liver injury ⬆ risk flare
SLE
Problems...

55. Points Of Discussion
• TB infection risk in SLE:
mechanism and susceptibility
factors
• Anti TB and its adverse events
in SLE
• Treatment SLE flare (MP) in TB
infection
Problems...

56. SLE flare
• FLARE ???
• Enchepalopathy
• NPSLE
• Seizure
• Anti TB liver injury
PADA PASIEN INI.....

57. Flare vs infection
Procal ⬆ in SLE 
infection

58. Flare vs infection
• CRP increased in 92% of the group with infection
• 89% of the group with lupus flare
• CRP tended to be higher in the group with non-viral
• but this did not reach significance (p=0.98).

59. Flare vs infection
• serum PCT increased significantly in patients with SLE
with non-viral infection compared with patients with
lupus flare

60. Flare vs infection
Flare vs infection
• Proteinuria
• Fever
• SLEDAI

61. Flare vs infection
REFERENCE :
• CRP ⬆ = infection non viral
• Procalcitonin ⬆ = infection non viral
• Proteinuria (+) = flare
• Fever (+) = infection
• SLEDAI ⬆ = flare
Pasien :
• CRP = NA
• Procalcitonin ⬆ = infection non viral
• Proteinuria = (-)
• Fever = (+)
• SLEDAI = 22
• Pasien mengalami (flare ?)

62. Tx SLE flare in infection

63. MP pulse dose

64. MP pulse dose

65. Tx severe Flare with infection
Pulse MP, hidroxycloroquin,
cycophospamide, rituximab

66. Tx severe Flare with infection

67. Flare vs infection
REFERENCE :
• MP pulse dose  infection ⬆
• MP pulse dose  mortality ± 20%
• Trombocytopenia  mortality ⬆
• IvIg may be the first line tx for
patient immunodeficient
Pasien :
• MP pulse dose (+)
• Infection ⬆ (procalcitonin ⬆)
• Trombocytopenia (+)
• IvIg ????
• Pemberian pulse MP sudah tepat karena mengalami flare berat
• Namun sayangnya pasien mengalami komplikasi dari Pulse MP
• Apakah ada pilihan lain? IvIg ?

68. Points Of Discussion
• Treatment SLE flare (MP) in TB
infection
1. Pulse MP meningkatkan resiko
infeksi dan mortalitas pada
kelompok berisiko
2. Pilihan lain selain pulse MP?
Problems...

69. CONCLUSION:
• SLE dan MP jangka panjang merupakan faktor risiko TB
• TB pada SLE bisa bersifat akut dengan gambaran klinis dan
rontgen tidak khas
• Anti TB liver injury sering terjadi pada pasien SLE dalam
pengobatan TB
• Anti TB liver injury dapat memicu flare
• Tatalaksana flare SLE pada infeksi berat menimbulkan
komplikasi dan mortalitas yang tinggi

70. THANK YOU....