Refractory SLE-Associated Immune Thrombocytopenia in a Resource-Limited Setting: A Case Report and Rationale for Early BAFF Inhibition

Abstract

Severe immune thrombocytopenia (ITP) is a life-threatening haematological manifestation of systemic lupus erythematosus (SLE) that may prove refractory to standard therapies, particularly in resource-limited settings where access to advanced biologic agents is restricted. We report a case of refractory SLE-associated thrombocytopenia and discuss the rationale for early B-cell activating factor (BAFF) inhibition. A 50-year-old Libyan man with SLE presented with severe thrombocytopenia, autoimmune haemolytic anaemia, and mucocutaneous bleeding requiring intensive care admission. Initial laboratory investigations revealed a platelet count of 2 × 10³/µL, haemoglobin of 5.1 g/dL, low complement levels, and a positive direct Coombs test. The patient received high-dose corticosteroids, intravenous immunoglobulin (IVIG), rituximab, mycophenolate mofetil, repeated blood product transfusions, and supportive care in accordance with current treatment recommendations. Platelet counts remained critically low for 27 days, with minimal response achieved on day 27 (>10 × 10³/µL), partial response on day 31 (>20 × 10³/µL), and a clinical response (>50 × 10³/µL) by approximately day 45. Complete haematological response was not attained, and platelet counts remained below the normal range at final follow-up. The delayed and incomplete response highlights the challenges of managing refractory SLE-associated thrombocytopenia in settings with limited therapeutic options. Emerging evidence suggests that BAFF inhibition with belimumab may complement rituximab by targeting autoreactive plasma cell survival pathways and improving haematological outcomes. This case underscores the unmet need for accessible biologic therapies in resource-limited settings and generates the hypothesis that earlier introduction of BAFF inhibition, alone or in combination with rituximab, may improve outcomes in refractory SLE-associated thrombocytopenia. Prospective studies are warranted to evaluate this therapeutic strategy.