Novel Sequential Therapy with Obinutuzumab and Telitacicept in Severe Lupus Nephritis with Glucocorticoid-Induced Avascular Necrosis of the Femoral Head - A Case Report

Sep 28, 2026

Clinical evidence is provided in a case report describing severe systemic lupus erythematosus (SLE) complicated by glucocorticoid-induced avascular necrosis (AVN) of the femoral head. Background outlines the immunologic rationale for combining B-cell depletion with BAFF/APRIL inhibition, addressing limitations of monotherapy and the risk of flare related to B-cell reconstitution. Sequential treatment with obinutuzumab followed by telitacicept is reported to achieve effective remission of lupus activity after recurrent, critically severe flares.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages8

Reading Time20 min

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Introduction

Case Report

Conclusions

Keywords

e-ISSN 1941-5923 © Am J Case Rep, 2025; 26: e950362 DOI: 10. 12659/AJCR.950362 Received: 2025.06.22 Accepted: 2025.10.01 Available online: 2025.10.14 Published: 2025.12.11 Authors’ Contribution: Study Design A Data Collection B Statistical Analysis C Data Interpretation D Manuscript Preparation E Literature Search F Funds Collection G BCDE BCDE BCD BCF AE AE ADE ADEF Corresponding Authors: Financial support: Conflict of interest: Novel Sequential Therapy with Obinutuzumaband Telitacicept in Severe Lupus Nephritis with Glucocorticoid-Induced Avascular Necrosis (AVN) of the Femoral Head: A Case Report 1 Yu Zhang* 1 Department of Nephrology, Center of Nephrology and Urology, The Seventh 1 Liqi Huang* Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong, PR China 2 Department of Pharmacy, The Seventh Affiliated Hospital, Sun Yat-sen University, 1 Na Li* Shenzhen, Guangdong, PR China 2 Xuelin Zeng 1 Zhihua Zheng 1 Xiaohua Wang 1 Yiqing Zhang 1 Chun Tang * Yu Zhang, Liqi Huang, and Na Li contributed equally to this work and share first authorship Chun Tang, e-mail: [tangch28@mail.sysu.edu.cn](tangch28@mail.sysu.edu.cn), Yiqing Zhang, e-mail: [zhangyq85@mail.sysu.edu.cn](zhangyq85@mail.sysu.edu.cn), Xiaohua Wang, [e-mail:](e-mail: wangxh95@mail.sysu.edu.cn)[ wangxh95@mail.sysu.edu.cn](e-mail: wangxh95@mail.sysu.edu.cn) Financial support was provided by Sanming Project of Medicine in Shenzhen (No.SZSM202411016); Shenzhen Municipal Science and Technology Innovation Commission (Grants No. JCYJ20210324123414040 and JCYJ20230807110715030) None declared Patient: Female, 16-year-old Final Diagnosis: Severe lupus nephritis with glucocorticoid-induced avascular necrosis of femoral head Symptoms: Cough with white mucus sputum • facial and bilateral lower limb edema • fever • pain in left knee and hip joint • proteinuria Clinical Procedure: — Specialty: Nephrology Objective: Unusual clinical course Background: Systemic lupus erythematosus (SLE) is a common systemic autoimmune disease characterized by immunemediated inflammation. Nearly half of SLE patients develop lupus nephritis (LN). Glucocorticoids are the most widely used foundational medication for SLE, yet their long-term use leads to a series of complications, such as opportunistic infections, diabetes, and femoral head osteonecrosis. Obinutuzumab is a humanized antiCD20 monoclonal antibody, whereas telitacicept is a fusion protein that blocks B-cell activating factor (BAFF) and A proliferation-inducing ligand (APRIL). Since monotherapy with B-cell depletion agents may lead to disease flare due to B-cell reconstitution and elevated levels of B-cell-stimulating factors (eg, BAFF), a new combination therapy involving B-cell depletion and BAFF/APRIL inhibitors could be an alternative to conventional therapies for patients, especially those with severe SLE. This combination has not yet been clinically applied. Case Report: We report the case of a 22-year-old woman with biopsy-proven class V LN 6 years ago, initially managed with prednisone, tacrolimus, and hydroxychloroquine. She developed glucocorticoid-induced femoral head necrosis 2 years after diagnosis and experienced recurrent lupus flares requiring multiple hospitalizations. At this admission for a critically severe lupus flare (SLEDAI score: 27), sequential treatment with Obinutuzumab followed by telitacicept resulted in effective remission of lupus activity. Conclusions: This is the first reported case of severe SLE treated with sequential therapy involving Obinutuzumab followed by telitacicept. The combination therapy of B-cell depletion plus BAFF/APRIL inhibition could be a promising and rational treatment approach for SLE patients, especially those with severe SLE, which warrants further clinical trials to validate the efficacy and safety of the therapeutic regimen. Keywords: Antibodies, Monoclonal • Glucocorticoids • Lupus Erythemat

FAQs

What is the clinical setting described in this case report?

The report describes a patient with severe lupus nephritis complicated by glucocorticoid-induced avascular necrosis of the femoral head and recurrent lupus flares.

Why is a sequential regimen with obinutuzumab followed by telitacicept considered biologically relevant?

The rationale is that B-cell depletion alone may be followed by disease flare due to B-cell reconstitution and increased BAFF-related stimulation, while BAFF/APRIL inhibition after depletion targets this pathway.

What outcomes are reported after sequential therapy?

Sequential treatment resulted in effective remission of lupus activity in the setting of a critically severe lupus flare.

Sep 28, 2026

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