NEUROPSYCHIATRIC SYSTEMIC LUPUS ERYTHEMATOUS: A DIAGNOSIS OF SUSPICION AND EXCLUSION

Abstract

SESSION TITLE: Critical Care Case Report Posters 49 SESSION TYPE: Case Report Posters PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: Systemic lupus erythematosus (SLE) is a chronic autoimmune process affecting multiple systems within the body. Known as neuropsychiatric SLE (NPSLE), diagnosis may require exclusion of other causes however prompt recognition will aid in appropriate symptomatic management. CASE PRESENTATION: A 48-year-old female with known diagnosis of SLE presented to the ED due to slurred speech and weakness. In the ED, patient was found to be tachycardic, otherwise vitals were stable. Initial labwork was significant for leukocytosis, microcytic anemia, thrombocytosis, AKI, and anion gap metabolic acidosis. Patient underwent CT brain and CTA head and neck which showed no acute abnormalities, no high-grade stenosis, dissection, or occlusion in the vessels of the head or neck. CT abdomen/pelvis and CXR also showed no acute abnormalities. Patient was initially started on broad spectrum antibiotics in setting of suspected sepsis of unknown origin. Patient was also started on a sodium bicarb drip and AKI as well as anion gap metabolic acidosis resolved however patient's slurred speech persisted. Patient also had episodes of hallucinations and delirium as well. MRI brain showed no acute intracranial process; it did show signs of chronic small vessel ischemic changes and moderate to advanced cerebral volume loss most pronounced in the frontal and temporal regions. Urinalysis was notable for proteinuria which was confirmed by two samples of elevated urine protein creatinine ratio. ESR, CRP, ferritin, and D dimer were noted to be elevated. CTA chest confirmed no pulmonary embolism. Rheumatology was consulted due to suspicion of lupus flare. IV antibiotics were discontinued, and patient was placed on Solu-Medrol 1000mg daily for three days and patient's mentation and slurred speech resolved. DISCUSSION: This case demonstrates the importance of clinical suspicion and awareness of NPSLE to allow for treatment in an appropriate timeframe. Many patients with SLE, estimated to be about one-third to one-half of patients, will experience neurologic or psychiatric symptoms throughout their disease course (1). NPSLE symptoms may precede or occur alongside with other manifestations of SLE disease activity (2) For most manifestations of NPSLE, no biomarkers or diagnostic tests are specific enough to attribute a patient's clinical presentation to SLE, however diagnosis should include exclusion of other causes. Identification and treatment is significant as some studies have found an increased risk of mortality in patients with NPSLE compared to SLE patients without NPSLE (3). CONCLUSIONS: In conclusion, clinicians should keep NPSLE in mind for patients with neurological or psychiatric symptoms specially when other causes have been ruled out. REFERENCE #1: Hanly JG;Urowitz MB;Su L;Bae SC;Gordon C;Wallace DJ;Clarke A;Bernatsky S;Isenberg D;Rahman A;Alarcón GS;Gladman DD;Fortin PR;Sanchez-Guerrero J;Romero-Diaz J;Merrill JT;Ginzler E;Bruce IN;Steinsson K;Khamashta M;Petri M;Manzi S;Dooley MA;Ramsey-Goldman R; Prospective analysis of neuropsychiatric events in an international disease inception cohort of patients with systemic lupus erythematosus. Annals of the rheumatic diseases. https://pubmed.ncbi.nlm.nih.gov/19359262/. Accessed March 31, 2023. REFERENCE #2: Hanly JG;Urowitz MB;Gordon C;Bae SC;Romero-Diaz J;Sanchez-Guerrero J;Bernatsky S;Clarke AE;Wallace DJ;Isenberg DA;Rahman A;Merrill JT;Fortin PR;Gladman DD;Bruce IN;Petri M;Ginzler EM;Dooley MA;Ramsey-Goldman R;Manzi S;Jönsen A;Alarcón GS;van Vollenhoven R. Neuropsychiatric events in systemic lupus erythematosus: A longitudinal analysis of outcomes in an international inception cohort using a multistate model approach. Annals of the rheumatic diseases. https://pubmed.ncbi.nlm.nih.gov/31915121/. Accessed March 31, 2023. REFERENCE #3: Ahn GY;Kim D;Won S;Song ST;Jeong HJ;Sohn IW;Lee S;Joo YB;Bae SC; Prevalence, risk factors, and impact on mortality of neuropsychiatric lupus: A prospective, single-center study. Lupus. https://pubmed.ncbi.nlm.nih.gov/29688144/. Accessed March 31, 2023. DISCLOSURES: No relevant relationships by Priyanka Batta No relevant relationships by Reena Patel No relevant relationships by Hena Yagnik