A 35-year-old Caucasian woman with proven SLE in 1998, according to the American College of Rheumatology criteria, had been effectively managed with hydroxychloroquine (250 mg/day) and methylprednisolone (8 mg/day) for many years. In May 2005 she was admitted to the rheumatology clinic with a flare-up of the disease, and presented with a pronounced butterfly rash, non-destructive arthritis, positive antinuclear antibody (ANA) 1:160 and anti-DNA(ds) 217, and proteinuria of 3.2 g/24 h. The remaining laboratory data (haematology, biochemistry) were normal. Electrocardiogram (ECG), chest x-ray, and echocardiography were normal. Abdominal echography revealed diffuse parenchymatous changes of the liver. Other abdominal organs were normal.
A renal biopsy was performed and revealed diffuse proliferative nephritis. Immunofluorescence showed 3 (+) pseudo-linear deposition of IgG, C3, C1q and fibrin as well as (+) segmental mesangial deposition of IgM. Before the renal biopsy a positive HBsAg was found with negative anti-HBc-IgM and normal liver enzymes. Within a month high concentrations of liver enzymes were detected: aspartate transaminase (AST) 64 U/l, alanine transaminase (ALT) 105 U/l, negative anti-HBc-IgM, and high virus replication (HBV-DNA—4 170 000 copies/ml). Liver biopsy revealed chronic hepatitis with minimal activity (total activity index score (TAIS)=1). The patient was treated with lamivudine, 100 mg daily, and the planned pulse methylprednisolone treatment for lupus nephritis was postponed. The patient continued the maintenance treatment with methylprednisolone (8 mg/day) but the hydroxychloroquine was stopped. After 3 months AST was 22 U/l and ALT 52 U/l, and the patient had no liver or other gastrointestinal complaints. On the background of lamivudine treatment, pulse methylprednisolone therapy was begun for diffuse lupus nephritis, 1 g/d for three consecutive days and thereafter once monthly for a period of 6 months. Maintenance therapy was 8 mg/day methylprednisolone plus lamivudine 1 tablet/day. After 6 months of treatment the liver enzymes returned to normal values (AST 31U/l, ALT 40 U/l), as well as ANA and anti-ds DNA antibodies. HBV replication was suppressed (0 copies/ml), and no proteinuria was found.