A case of systemic lupus erythematosus with multiple nodules in the bilateral lungs and vertebrae

We encountered a case of a middle-aged woman with systemic lupus erythematosus. As the patient had progressive peripheral neuropathy including foot drop, we intended to treat her with intensive immunosuppressive therapy as soon as possible. Pretreatment assessment, however, revealed multiple nodular lesions in the lungs and bones, suggesting disseminated tumor metastasis or miliary tuberculosis. To our surprise, gallium and bone scintigraphy as well as cytodiagnosis revealed no sign of malignancy or infection, leading us to suspect the presence of another multisystem disorder. The presence of subependymal nodules and a periungual fibroma strongly suggested tuberous sclerosis (TS). A genetic test revealed a mutation in the TSC1 gene and confirmed the diagnosis. Thus, the multiple nodular lesions were most likely a hyperplasia due to TS. Although the odds of a comorbidity of more than one multisystem disorder are considered to be quite low, it should be kept in mind that when such a situation does exist, the comorbidity may make the presenting symptoms extremely diverse.