Neuropsychiatric Lupus: A Challenging Journey of a Patient With Pulmonary Tuberculosis

Systemic lupus erythematosus (SLE) is a disease that affects multiple systems in the body. Due to its variable manifestations, it can at times pose challenges for physicians to hold SLE as the culprit behind an affected system. This is most true when encountering patients with neuropsychiatric manifestations of SLE. We present a case of a 38-year-old female with known SLE limited to skin involvement and on treatment for active pulmonary tuberculosis (TB), yet otherwise healthy, who presented with acute fever associated with generalized tonic-clonic seizures. She was investigated for meningoencephalitis with a cerebrospinal fluid (CSF) analysis not being fully conclusive and with imaging features suggestive of viral encephalitis. However, despite receiving optimal care for causes of bacterial, viral, and tuberculous meningitis the patient continued to deteriorate and started to develop predominant psychiatric symptoms in the form of confusion and combative behavior requiring pharmacological restraint. Hence a trial of immunosuppressives was given with a presumptive diagnosis of neuropsychiatric lupus with IV methylprednisolone followed by a course of IV cyclophosphamide. However, this treatment proceeded with caution due to the fear of disseminated tuberculosis for which she did not show any sign of in the subsequent weeks. The patient showed modest clinical and radiological improvement and hence the treatment was continued. The case highlights the uncertainty that may precede a diagnosis of neuropsychiatric lupus and the challenges in treating it in patients with active mycobacterial infection.