Successful treatment of massive intractable pericardial effusion in a patient with systemic lupus erythematosus with tocilizumab

Abstract

A 51-year-old Japanese woman developed systemic lupus erythematosus (SLE) in 1995. In August 2005, she had massive pericardial effusion due to lupus pericarditis, which was compromising her circulation. Methylprednisolone pulse, intravenous cyclophosphamide pulse and pericardiocentesis were all ineffective. The pericardium was cut surgically to create a passage to drain the liquid into the pleural cavity. The procedure was temporarily effective; however, massive liquid accumulated in the pleural cavity within 1 year. Oral tacrolimus and topical betamethasone injection were ineffective. Since the interleukin-6 (IL-6) level in the effusion was markedly increased (1160 pg/ml), tocilizumab was administered intravenously at a dose of 8 mg/kg every 4 weeks. The effect was astonishing and only a residual amount of pericardial effusion remained. Prednisolone was tapered successfully from 15 to 5 mg daily. Tocilizumab is a treatment of choice when we confront an intractable serositis with massive effusion in SLE, if the IL-6 level is high.

Figure 1

Chest radiographs showing pericardial effusion decreased after placement of fenestration into the pericardium. (A) Before pericardial fenestration, (B) after pericardial fenestration.

Figure 2

Chest radiographs showing a gradual decrease in pericardial effusion after tocilizumab treatment. (A) Before tocilizumab treatment, (B) 1 month, (C) 6 months and (D) 1 year after tocilizumab treatment.

Figure 3

Lateral view of chest radiographs showing fluid in pleural space after tocilizumab treatment. (A) After 13 months and (B) after 1.5 years of treatment.

Figure 4

Clinical course of the present case.