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Difficulty: MediumRheumatology and Immunology

A 2222-year-old woman is brought to the emergency department by her college roommate due to bizarre behavior over the past 44 days. The roommate states that the patient has locked herself in her room, claims that hidden cameras are recording her thoughts, and frequently talks to people who are not present. She has no personal or family history of psychiatric illness. Over the past month, the patient has complained of severe fatigue, diffuse joint pain, and increased hair shedding. Her temperature is 37.9∘C37.9^{\circ}C (100.2∘F100.2^{\circ}F), blood pressure is 146/92146/92 mm Hg, and pulse is 9898/min. Physical examination reveals an erythematous, scaling rash across her cheeks and the bridge of her nose that spares the nasolabial folds. Painless ulcers are noted on the hard palate. The proximal interphalangeal and metacarpophalangeal joints are mildly swollen, warm, and tender to palpation bilaterally.

Laboratory studies show:
TestResult
Hemoglobin9.69.6 g/dL
Leukocytes3,100/mm33,100/mm^3
Platelets98,000/mm398,000/mm^3
Serum creatinine1.61.6 mg/dL
Thyroid-stimulating hormone (TSH)2.42.4 mU/L (normal: 0.5−5.00.5-5.0 mU/L)
Free T41.21.2 ng/dL (normal: 0.9−2.40.9-2.4 ng/dL)
Urinalysis3+3+ protein, 10−1510-15 erythrocytes/hpf, negative leukocyte esterase

Which of the following is the most appropriate initial treatment targeting the underlying etiology of this patient's condition?

  1. Intravenous methylprednisoloneAnswer
  2. B
    Intravenous ceftriaxone and vancomycin
  3. C
    Oral risperidone and psychiatric admission
  4. D
    Oral sertraline monotherapy
  5. E
    Oral levothyroxine therapy

Answer

Intravenous methylprednisolone
The correct answer is high-dose intravenous corticosteroids. This patient presents with acute psychosis in the setting of severe, undiagnosed Systemic Lupus Erythematosus (SLE). Her clinical picture features multiple classic SLE criteria: malar rash, painless oral ulcers, inflammatory arthritis, alopecia, pancytopenia, and lupus nephritis (proteinuria, hematuria, and elevated creatinine). The acute onset of hallucinations and paranoia represents neuropsychiatric SLE (lupus cerebritis), a severe, organ-threatening manifestation of the disease. The primary treatment for life-threatening or organ-threatening SLE flares is immediate immunosuppression with high-dose intravenous corticosteroids (e.g., methylprednisolone), often followed by cyclophosphamide or mycophenolate mofetil.

Step-by-Step Solution

1
Analyze the patient's systemic symptoms and physical examination findings.
The patient has a malar rash, oral ulcers, nondeforming polyarthritis, and alopecia.
These are classic clinical criteria for Systemic Lupus Erythematosus (SLE).
2
Evaluate the laboratory results.
Pancytopenia (anemia, leukopenia, thrombocytopenia) and acute kidney injury with proteinuria and hematuria are present.
These findings confirm hematologic and renal (lupus nephritis) involvement of SLE, demonstrating a severe systemic flare.
3
Interpret the acute psychiatric presentation in the context of the systemic disease.
The acute onset of hallucinations and paranoia over 4 days in a patient with an active SLE flare points to neuropsychiatric SLE (lupus cerebritis/psychosis).
Medical causes of psychosis must be ruled out before diagnosing primary psychiatric conditions.
4
Determine the appropriate disease-modifying treatment for organ-threatening SLE.
High-dose intravenous corticosteroids are required.
Severe SLE manifestations (CNS involvement and active nephritis) require aggressive immunosuppression to halt end-organ damage.

Key Concept

Neuropsychiatric Systemic Lupus Erythematosus (SLE) requires urgent recognition of underlying autoimmune etiology and immediate treatment with high-dose intravenous corticosteroids.
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Topics

Rheumatology and Immunology

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