# Case Report: Relapsing systemic lupus erythematosus treated with dual rituximab and anifrolumab therapy

## TL;DR

A 42-year-old woman with severe lupus and related conditions improved significantly after treatment with two biologic drugs, rituximab and anifrolumab.

## Contribution

This is the first reported case of successful treatment of refractory lupus using dual biologic therapy with rituximab and anifrolumab.

## Key findings

- The patient showed marked neurologic improvement after starting rituximab and corticosteroids.
- Reintroducing anifrolumab while continuing rituximab led to significant improvement in cutaneous symptoms of Rowell Syndrome.
- Dual therapy with rituximab and anifrolumab was effective in managing both neurologic and cutaneous manifestations of refractory SLE.

## Abstract

While biologic monotherapy is commonly used in the management of moderate-to-severe systemic lupus erythematosus (SLE), limited data exists regarding the efficacy and safety of dual biologic therapy in SLE. We report the case of a 42-year-old woman with a history of SLE complicated by Rowell Syndrome (RS) that was managed on anifrolumab and a recent diagnosis of moyamoya disease, who presented with new-onset lower extremity weakness. Laboratory testing was notable for active lupus serologies, and magnetic resonance angiography (MRA) findings were consistent with worsening moyamoya syndrome. Given the clinical and radiographic findings, a diagnosis of CNS lupus was suspected. Anifrolumab was discontinued and she was started on pulse dose corticosteroids and rituximab, resulting in marked neurologic improvement. However, she subsequently experienced a flare of RS. Anifrolumab was reintroduced while she remained on rituximab, leading to significant clinical improvement of her cutaneous symptoms. To our knowledge, we present the first case of successful treatment of refractory SLE with both cutaneous and neurologic involvement utilizing dual biologic therapy with rituximab and anifrolumab.