[Hyperosmolality in central nervous system lupus as a possible complication that results in prolonged consciousness...

We describe a patient with systemic lupus erythematosus (SLE) with lupus psychosis, who showed prolonged consciousness disturbance due to hyperosmolality. A 51-year-old Japanese woman with SLE was admitted to our hospital for the evaluation and treatment of consciousness disturbance on March 5, 1994. She had not been given prednisolone since 1984, and had been depressive since January 1994. She was diagnosed as active SLE with lupus psychosis due to the presence of thrombocytopenia, proteinuria, positive anti-nuclear antibody (x10,240) as well as the elevation of cerebrospinal fluid (CSF) IL-6 level. A treatment with methylprednisolone (mPL) 100 mg/day was started along with 2 courses of steroid pulse therapy (mPL 1 g/day for 3 consecutive days). She recovered partially from the central nervous system manifestations with a decrease in CSF IL-6 level 2 weeks after this treatment. However, her consciousness level was exacerbated again thereafter. Blood examination disclosed the elevation of plasma osmolality (319 mOsm/kg) with poor responses of plasma antidiuretic hormone (4.6 pg/ml). She died from systemic aspergillosis on April 26, 1994. Pathological examination on autopsy showed no abnormality in hypothalamus and pituitary gland. It is suggested that this patient was complicated with lupus psychosis as well as hyporesponsiveness of osmoreceptor. Rheumatologists should be aware of this complication in patients with CNS lupus as a possible cause for intractable CNS manifestations.