Acute psychosis as the presenting manifestation of lupus

Unusual Presentations of Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) often develops during adolescence, may affect any organ system, and may present with a wide variety of signs and symptoms. It is critical to recognize the unusual manifestations of SLE in order to make a prompt diagnosis. Earlier diagnosis allows for appropriate treatment and ultimately decreases morbidity and mortality.

Tonic-Clonic Seizure in Patient With SLE: Posterior Reversible Encephalopathy Syndrome, or a Neuropsychiatric Manifestation of SLE?

Posterior reversible encephalopathy syndrome (PRES) is a clinically and radiologically diagnosed reversible sudden onset disease with many neurological symptoms. SLE is the most common cause of PRES among autoimmune diseases. Many factors, such as SLE activity, hypertension, hematological and renal diseases, lymphopenia dyslipidemia, and immunosuppressive treatments, can trigger PRES in SLE. We wanted to draw attention to the difference between neuropsychiatric systemic lupus erythematosus (SLE) and PRES in a patient with SLE and the triggers for developing PRES in SLE by presenting a hypertensive patient on immunosuppressive therapy who had just started haemodialysis treatment and had generalised tonic-clonic seizures.

Psychotic symptoms in a patient with Systemic Lupus Erythematosus: A diagnostic dilemma between lupus psychosis and steroid induced psychosis

Introduction

Systemic Lupus Erythematosus (SLE) is a chronic auto-immune disorder with the involvement of multiple organ systems. It is more common in females.

Case presentation

Here, we present a case of 12-year-old female, known case of SLE with lupus nephritis, presenting with neuropsychiatric symptoms. She was under steroids as well for a few weeks due to flare-up of symptoms prior to that. Due to this, there was a diagnostic dilemma between lupus psychosis and steroid induced psychosis.

Clinical discussion

Approximately one third to half of the patients may have neurological involvement in Systemic Lupus Erythematosus. However, neuropsychiatric symptoms in them could be due to corticosteroids, which are frequently used in treatment. There are no definitive and easily available laboratory markers to distinguish these two aetiologies.

Conclusions

Systemic Lupus Erythematosus patients, who are on steroids, with neuropsychiatric features should be assessed adequately. As there are no specific guideline and biomarkers to distinguish between these two, meticulous evaluation is necessary for appropriate management.

Clinical profile of patients with lupus psychosis in a Colombian cohort

The objective of this study is to describe the frequency and the clinical, paraclinical, and treatment profile of patients with lupus psychosis in a Colombian cohort of patients with systemic lupus erythematosus (SLE). This retrospective cohort study evaluated epidemiological and clinical characteristics, results of neuroimaging, analysis of the cerebrospinal fluid, treatment, and disease evolution in patients with lupus psychosis. Among 2,479 patients with SLE, six female patients aged between 20 and 50 years with a diagnosis of lupus psychosis were identified. In two patients, psychosis was present at disease onset and in the other four, SLE was already present, although the majority of them were diagnosed less than two years prior to the onset of psychosis. The entire cohort had high disease activity as measured by SLEDAI-2K. We found concomitant cutaneous, joint, and hematological alterations. Cerebrospinal fluid data were obtained in half of the patients and were normal. We performed brain tomography on most of our patients, which was almost always described as normal. In 5 out of 6 patients, the induction therapy to treat psychosis was based on steroids, and in the majority of them, a resolution of psychiatric symptoms was observed after initiating treatment. Lupus psychosis is a rare event that usually occurs early in the course of the disease and is associated with other manifestations of SLE. This investigation mainly found concomitant cutaneous, joint, and hematological manifestations, with a favorable outcome after treatment, as described in the literature.

Prevalence of Anti-Nuclear Antibodies and Anti-Phospholipid Antibodies in an Egyptian Cohort with Schizophrenia: A Case-Control Study

BACKGROUND

Psychiatric disorders, including schizophrenia could herald other manifestation(s) of systemic lupus erythematosus (SLE) potentially hindering timely and optimal management. Moreover, schizophrenia is among the described 'extra-criteria' manifestations of anti-phospholipid syndrome (APS). Hence, screening schizophrenia patients for SLE and APS may pose diagnostic and therapeutic implications.

OBJECTIVES

Examine schizophrenia patients with no overt connective tissue disease(s) manifestation(s) for clinical and/or serologic evidence of SLE and/or APS.

METHODS

The study included 92 schizophrenia patients [61 (66.3%) males] and 100 age- and gender-matched healthy controls. Both groups were tested for anti-nuclear antibodies (ANAs), anti-double stranded deoxyribonucleic acid (anti-dsDNA) antibodies, complement 3 (C3) and C4, and criteria anti-phospholipid antibodies (aPL) [anticardiolipin Immunoglobulin (Ig) G and IgM, anti-beta-2-glycoprotein I IgG and IgM, and lupus anticoagulant (LAC)].

RESULTS

The patients' mean age and disease duration were 28.8 ± 8.1 and 5.7 ± 2.2 years, respectively. The prevalence of ANA positivity, height of titre, and pattern was comparable between patients and controls (p = 0.9, p = 0.8 and p = 0.1, respectively). Anti-dsDNA antibodies and hypocomplementemia were absent in both groups. A significantly higher frequency of positive LAC was observed among patients compared with controls (7.6 % vs. 1 %, p = 0.02), whereas other aPL were comparable between both groups. None of the patients or controls demonstrated clinically meaningful (medium or high) aPL titres.

CONCLUSION

In our study, schizophrenia was solely associated with LAC. Thus, in the absence of findings suggestive of SLE or APS, routine screening for both diseases is questionable.

Neuropsychiatric Systemic Lupus Erythematosus: A 2021 Update on Diagnosis, Management, and Current Challenges

Patients with systemic lupus erythematosus (SLE) experience neuropsychiatric symptoms. The term neuropsychiatric SLE (NPSLE) is a generic term that refers to a series of neurological and psychiatric symptoms directly related to SLE. In approximately 30% of patients with neuropsychiatric symptoms, SLE is the primary cause (NPSLE), and symptoms manifest more frequently around SLE onset. Neurovascular and psychotic conditions can also lead to NPSLE. Pathogenesis of NPSLE is implicated in both neuroinflammatory and ischemic mechanisms, and it is associated with high morbidity and mortality. After diagnosing and assigning causality, NPSLE treatment is individualized according to the type of neuropsychiatric manifestations, type of the predominant pathway, activity of SLE, and severity of the clinical manifestations. There are many problems to be addressed with regards to the diagnosis and management of NPSLE. Controlled clinical trials provide limited guidance for management, and observational cohort studies support symptomatic, antithrombotic, and immunosuppressive agents. The purpose of this review was to provide a detailed and critical review of the literature on the pathophysiology, diagnosis, and treatment of NPSLE. This study aimed to identify the shortcoming in diagnostic biomarkers, novel therapies against NPSLE, and additional research needs.