West Nile encephalitis mimicking neuropsychiatric lupus in a patient with systemic lupus erythematosus

A man in his 70s with known systemic lupus erythematosus (SLE) was admitted with confusion, worsening proteinuria and cutaneous vasculitis despite adherence to his home immunosuppressive regimen. Admission laboratories were consistent with active lupus. Despite treatment with pulse–dose glucocortico...

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Bibliographic Details
Published in:BMJ case reports 2019-07, Vol.12 (7), p.e229537
Main Authors: Iyer, Neena R, McCune, W Joseph, Wallace, Beth I
Format: Article
Language:English
Subjects:
Aged
Antigens
Biopsy
Case reports
Chicken pox
Confusion - virology
Diagnosis, Differential
Disease
Drug dosages
Electroencephalography
Encephalitis
Fatal Outcome
Glucose
Herpes viruses
Humans
Immunoglobulins
Immunosuppressive Agents - therapeutic use
Infections
Lupus
Lupus Erythematosus, Systemic - complications
Lupus Erythematosus, Systemic - physiopathology
Lupus Erythematosus, Systemic - virology
Lupus Vasculitis, Central Nervous System - diagnosis
Male
Medical laboratories
Nervous system
Patients
Proteins
Proteinuria - virology
Spinal Puncture
Systematic review
Unusual Association of Diseases/Symptoms
Urine
West Nile Fever - diagnosis
West Nile Fever - physiopathology
West Nile Fever - therapy
West Nile virus
West Nile virus - isolation & purification
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Description
Summary:A man in his 70s with known systemic lupus erythematosus (SLE) was admitted with confusion, worsening proteinuria and cutaneous vasculitis despite adherence to his home immunosuppressive regimen. Admission laboratories were consistent with active lupus. Despite treatment with pulse–dose glucocorticoids and intravenous immunoglobulin, he developed worsening mental status and meningeal signs. Investigations revealed cerebrospinal fluid (CSF) neutrophilic and plasmacytic pleocytosis and negative cultures. Empiric treatment for SLE flare with potential neuropsychiatric involvement was continued while workup for altered mental status was ongoing. Ultimately, West Nile encephalitis was diagnosed by CSF serologies, and steroids were tapered. Altered mental status in a patient with SLE has a broad differential, and primary neuropsychiatric SLE should be considered only after exclusion of secondary causes. Although evidence of end-organ SLE activity usually lends support to a neuropsychiatric SLE diagnosis, in this case, serological and clinical evidence of SLE activity may have been triggered by acute viral infection.
ISSN:1757-790X
1757-790X
DOI:10.1136/bcr-2019-229537