ANSWER 34
This patient has a number of important symptoms, particularly the generalized seizures,
auditory hallucinations, fever, arthralgia and alopecia. Investigations show low haemo-
globin, white cells and platelets with impaired renal function and blood, protein and cells
in the urine. The CSF contains white cells and a high protein content but no organisms.
This is a multisystem disease and the symptoms and investigations are explained best
by a diagnosis of systemic lupus erythematosus(SLE). SLE is an autoimmune condition
which is about nine times more common in women than men, and is especially common
in African-Caribbean and Asian individuals. It varies in severity from a mild illness caus-
ing a rash or joint pains, to a life-threatening multisystem illness. In the brain, SLE causes
a small-vessel vasculitis and can present with depression, a schizophrenia-like psychosis,
fits, chorea and focal cerebral/spinal cord infarction. Lumbar puncture usually shows a
raisedleucocyte count and protein level. A Coombs’-positive haemolytic anaemia may occur.
Leucopenia and thrombocytopenia are common. Glomerulonephritis is another common
manifestation of lupus and may present with microscopic haematuria/proteinuria, nephrotic
syndrome or renal failure. Arthritis commonly affects the proximal interphalangeal and
metacarpophalangeal joints and wrists, usually as arthralgia without any deformity.
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- Meningitis/encephalitis
- ‘Recreational’ drug abuse, e.g. cocaine
- Cerebral tumour
- Acute alcohol withdrawal: delirium tremens
- Hypertensive encephalopathy
Differential diagnosis of the combination of headaches/psychiatric features/fitsThis patient needs urgent antihypertensive treatment to lower her blood pressure, and
anticonvulsant treatment. Blood should be sent for anti-DNA antibodies (present in SLE)
and complement C3 and C4 levels (depressed in SLE). A renal biopsy will provide histo-
logical evidence of the severity of the lupus nephritis. As soon as active infection has been
excluded, treatment should be started with intravenous steroids and cytotoxic agents such
as cyclophosphamide. Plasma exchange may be added in severe or resistant cases.
- SLE is particularly common in young African-Caribbean women.
- SLE may present with predominantly neurological or psychiatric features.
- A low white cell count or low platelet numbers are often a suggestive feature of SLE.