Acute psychosis as the presenting manifestation of lupus: case reports

Abstract

Introduction: Systemic lupus erythematosus (SLE) is an autoimmune disorder that affects multiple organs with a wide range of clinical manifestations. Neuropsychiatric manifestation (NPSLE) is present among 28–40% of the SLE patients. Psychosis is rarely the only initial symptom of lupus, as neuropsychiatric lupus is often associated with systemic activity. We present two cases of young ladies presenting with acute psychosis as the predominant symptom and further diagnosed with SLE disease. Case reports: Case 1 A 20-year-old female, unmarried, presented to the Psychology Department with acute behavioral abnormality associated with staring, insomnia and, aggressive behavior, hearing voices for the last 3 days. No other psychiatric or neurological symptoms; she was taking 20 mg oral prednisolone prescribed according to a history of fatigue, low-grade fever, loss of appetite, pain in almost all joints, and myalgia for the last 1 month. There was no sign of focal neurological deficit or meningeal irritation. Examination of other systems did not find any clinical abnormality except for the presence of photosensitivity. A psychiatric consultation was ordered. Laboratory tests: white blood cells 3200 cell/mm3 (range=4000–11 000) with normal differentiation, hemoglobin 9.2 mg/dl (range=12.5–16), platelet 90 000/dl (range=150 000–400 000), C-reactive protein (CRP) 65 mg/l (n≤6), and erythrocyte sedimentation rate (ESR) 100 mm/h(range=0–20). anti-nuclear antibody (ANA) profile which was positive in 1:320 dilution, homogenous type, along with anti-ds-DNA positive (+), decreased C3 and C4. The diagnosis of SLE was done according to the European League Against Rheumatism/American College of Rheumatology Classification Criteria (EULAR/ACR Criteria). Case2 A 37-year-old married female with 3 children presented to the Psychology Department with disorientation, staring, hearing voices, seeing images of people who want to hurt her, refusing to respond to people, and insomnia for the last 10 days. She had complained of fatigue and low-grade fever for last month. A psychiatric consultation was ordered, and the patient was managed with an injection of haloperidol 5 mg BD. Laboratory tests: white blood cells 7300 cells/mm3 (range=4000–11 000) with normal differentiation, hemoglobin 8.7 mg/dl (range=12.5–16), platelet 90 000/dl (range=150 000–400 000), reticulocyte:1.4, CRP 7 mg/l (n≤6), and ESR 50mm/h (range=0–20). The ANA profile was positive in 1:320 dilution, homogenous type, along with the anti-ds-DNA negative (−), decreased C3, and normal C4. Brain magnetic resonance imaging (MRI) showed a high white matter signal around the lateral ventricles and in the semi-oval centers. Mild dilation of the lateral ventricles and slight elevation of the left insular and medial temporal lobe signal. Conclusion: Our case reports showed that organic disorders should be considered while evaluating acute psychosis, especially autoimmune disorders. The presence of laboratory features like anemia, elevated ESR, and elevated CRP should be taken with utmost importance.