Treatment of active proliferative LN can be challenging, especially for patients who do not respond to first line treatments or those who develop severe infectious complications. In this subset of patients, substantial risk of progression to end stage renal disease must be weighted about the potentially fatal risk of infections. Before the introduction of immunosuppressive therapy, the prognosis of LN was extremely dismal [
14]. Despite the great improvement in modern standard of care, the presence of LN is associated with an extremely high risk of end stage renal disease (ESRD) and still an increased risk of death; also, the presence of renal insufficiency is linked to lower health-related quality of life [
2]. Premature atherosclerosis, possibly due to the chronic inflammatory state of SLE [
15], is now recognized as one of the leading causes of morbidity and mortality in SLE [
16]. Nevertheless, it should be kept in mind that a substantial contribution to mortality in LN patients is conferred by serious infections [
16] (especially in under-developed countries) and active disease. Cryptococcal meningitis is the most commonly reported invasive fungal diseases in SLE [
17,
18]; most commonly, invasive fungal infections present early in the disease course, are associated with high disease activity and high-dose steroid use, and bear a substantial risk for fatal outcome [
17]. The diagnosis of invasive fungal infections may be complicated by the overlap of clinical characteristics with active SLE; in our case, the presence of meningeal symptoms was initially attributed to possible SLE involvement of the central nervous system; nevertheless, this last hypothesis was rapidly discarded an appropriate diagnostic procedure (lumbar puncture) was performed, demonstrating the presence of fungal meningitis. After appropriate antibiotic treatment was instituted, in accordance with patient’s will and after discussion with her mother we decided to insist on immunosuppressive treatment despite complications and poor tolerance aiming at minimizing the consistent risk of rapid progression to ESRD and of extra-renal manifestations of SLE. Two major randomized trials (BLISS-52 [
8] and BLISS-76 [
9]) validated the use of Belimumab in addition to standard of care for the treatment of active SLE; apart from demonstrating the clinical efficacy of Belimumab versus placebo, these studies showed that rates of serious adverse events, including infectious complications, did not differ substantially across groups. Moreover, post-hoc subgroup analyses of patients with LN in the two BLISS studies indicated greater renal disease improvements with Belimumab than with placebo [
19]. Since data available at the moment suggested that infections do not seem to be a major concern in patients treated with Belimumab, and considering the available reports [
20‐
22] of successful treatment of LN with Belimumab and the suggestions derived from the BLISS trials [
11,
19], after retrieval of ethical committee approval we proceeded with this treatment in adjunction to steroids. Belimumab is so far well tolerated by our patients, with absence of notable side effects or adverse events. Belimumab resulted in a strong improvement in parameter related to disease activity and in a consistent reduction in proteinuria and microhematuria. Consistent with results of previously mentioned clinical trials [
8,
9], Belimumab resulted in a fair reduction in SLEDAI score. We hope that in the near future ongoing clinical trials [
23] can establish a clear role for Belimumab in the treatment of LN, and better identify those patients who may benefit the most from this treatment. Meanwhile, we suggest that Belimumab may be used off-label in that subset of patients with active LN who develop severe infectious complications after first and second-line conventional treatments for LN or who are intolerant to them.