A 38-year-old female with systemic lupus erythematosus (SLE) initiated belimumab treatment. One month later, she presented with a reddish painful swelling on her right lower leg.She was treated with ceftriaxone and vancomycin. However, novel erythematous papules and indurated nodules appeared on both her lower legs. Skin biopsy revealed microabscess formation with mixed cell granuloma surrounded by inflammatory cell infiltration within the dermis with subcutaneous fat tissue. A large number of acid-fast bacilli were observed with Ziehl–Neelsen staining. DNA sequencing of both the hsp65 and the 16S rRNA sequences showed a 100% match with the corresponding region of Mycobacterium haemophilum. Mycobacterial culture revealed satellite growth enhancement on Middlebrook 7H11 agar plates around a paper strip containing hemin. She was treated with levofloxacin, rifabutin, and ethambutol. Within 13 months, her cutaneous lesions improved markedly without any side effects. The B cell-targeted biologic belimumab, a fully humanized IgG1γ monoclonal antibody that inactivates B lymphocyte stimulator, has been considered to be beneficial for active SLE. However, this therapy could increase the risk for the development of biologic therapy-associated mycobacterial infections, both tuberculosis and nontuberculous mycobacteria infections.

Two cases of hair loss due to coronavirus disease 2019 (COVID-19) sequelae as known as Long COVID were successfully treated with ninjin’yoeito. Case 1 was a 45-year-old woman who complained of hair loss about 2 months after COVID-19 (moderate II in Japanese criteria). Case 2 was a 50-year-old woman who complained of hair loss about 2 months after COVID-19 (mild). In all cases, hair loss stopped next month after treatment with ninjin’yoeito. And their hair began to grow 2 months later administration, the depression caused by hair loss improved as the symptoms improved. Hair loss is one of the symptoms with blood [TM1] deficiency, and patients suffering from Long COVID are also with qi deficiency. We gave ninjinʼyoeito for pattern of both qi and blood [TM1] deficiency with reference to traditional key of treatment, and it contributed to the improvement of symptoms.