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An opportunistic infection is a known, although underdiagnosed, complication of systemic lupus erythematosus (SLE). A 48-year-old woman with a recent diagnosis of SLE was admitted to the hospital because of a fever, confused state, and convulsive episode. Her symptoms were interpreted as being compatible with lupus cerebritis. Treatment with methylprednisolone resulted in a temporary improvement in the patient's condition. Nevertheless, during the next few weeks, her physical and mental condition deteriorated, and she died of massive pulmonary emboli. An autopsy revealed no signs of lupus cerebritis; however, disseminated cerebral toxoplasmosis was found. Cerebral toxoplasmosis is a rare complication of SLE that may be misdiagnosed as lupus cerebritis.
Opportunistic infections are common in patients with systemic lupus erythematosus (SLE) and are a major cause of death. Opportunistic infections involving the central nervous system (CNS) are uncommon, although Cryptococcus.
have been reported as CNS pathogens. Because brain vasculitis is extremely common in patients with SLE, distinguishing an infection of the eNS from vasculitis can be a diagnostic challenge. In such a case, misdiagnosis may be fatal.
We describe a patient with SLE and CNS manifestations that were suspected to be part of the primary disease and were treated as such; however, at autopsy, they were found to be cerebral toxoplasmosis.
Report Of Case
A 48-year-old woman was referred to the hospital in January 1996 because of a high fever, confused state, and convulsive episode. At age 40 years, she had undergone a subtotal thyroidectomy because of a multinodular goiter. A month before the current hospitalization, she had been hospitalized elsewhere for peripheral edema, and nephrotic syndrome was diagnosed. Histologic findings were consistent with membranous glomerulonephritis, a manifestation of SLE. Methylprednisolone, 60 mg/d, was begun.
On admission to our hospital, the patient had a fever (39.3°C), a resting pulse rate of l00/min, a few oral ulcers, and a facial butterfly rash. Initial assessment revealed an increased erythrocyte sedimentation rate, anemia (hemoglobin concentration, 8.9 g/dl.), and leukopenia (leukocyte count, 2.5 × l0
/L). Results of kidney function tests were normal, and no proteinuria was noted. Antinuclear antibody was positive at a titer of 1–160, as was anti-double-stranded DNA.
Computed tomography of the brain revealed mild dilatation of the lateral and third ventricles and small calcifications in the basal ganglia (Figure 1). Electroencephalography showed general irregular deceleration. The patient was treated with ciprofioxacin because of a suspected urinary tract infection. The diagnosis of SLE was confirmed on the basis of her having 6 of the 1982 revised criteria for the classification of SLE: malar rash, renal disease with heavy proteinuria, oral ulcers, leukopenia, high antinuclear antibody, and positive anti-double-stranded DNA.
Because she was confused and had a convulsive event, lupus cerebritis was suspected, and the dose of methylprednisolone was increased. She had an uneventful recovery within a few days.
Figure 1Computed tomographic scan of the brain of a 48-yearold woman, demonstrating calcifications in the basal ganglia.
A week later, the patient was referred to the hospital after another “convulsive event”; she was in a confused state and had a temperature of 37.8°C. A lumbar puncture was performed. Findings on a cerebrospinal fluid (CSF) examination were normal except for an increased protein level (150 mg/dL) and oligoclonal bands of γ-globulin. No bacteria were observed, and CSF cultures were negative. Findings on repeated electroencephalography and computed tomography of the brain were normal. Corticosteroid treatment was continued because lupus involvement of the CNS was assumed.
During the next 2 weeks, the patient's fever disappeared, but her mental and physical condition deteriorated, with apathy and depression, until she became bedridden. Deep venous thrombosis developed in her left thigh, and she underwent complete anticoagulation. However, acute respiratory failure occurred and led to her sudden death.
Pathologic Findings
Pathologic examination revealed a massive pulmonary embolism that probably caused our patient's death. Although membranous glomerulonephritis was found, no signs of lupus cerebritis were detected.
Sections of the brain disclosed numerous necroinflammatory foci within the basal ganglia and cerebral gray matter. These foci were remarkable for the presence of microcystic structures that were 18 to 40 μrn in diameter. The cysts were filled with minute round basophilic structures consistent with bradyzoites of Toxoplasma (Figure 2). Plasma cells and lymphocytes were observed surrounding the cysts, inflammatory cells, and macrophages. Blood vessels showed perivascular lymphoid infiltration, endothelial swelling, and thrombosis. Immunohistochemical staining for Toxoplasma was positive in the cysts, an outcome confirming the histological diagnosis (Figure 3).
Figure 2Brain tissue showing inflammatory cells and several cysts filled with Toxoplasma (hematoxylin-eosin, original magnification × 400).
Toxoplasma gondii infection is a common disease worldwide. Acute infection in an immunocompetent host is usually asymptomatic.
The 3 major pathologic patterns of cerebral toxoplasmosis are diffuse encephalopathy with or without seizures, meningoencephalitis, and singular or large progressive mass lesions.
Other causes of basal ganglia calcifications include cytomegalovirus, rubella, herpes simplex, hypoparathyroidism, pseudohypoparathyroidism, pseudopseudohypoparathyroidism, Cockayne syndrome, Wilson disease, Fahr syndrome, anoxia, lead poisoning, carbon monoxide poisoning, and familial and idiopathic causes.
The absence of any other lesions in the brain of our patient suggests that the calcifications were benign and were not related to toxoplasmosis. A quantitative serum CRP determination, probably with a finding of high levels, could be a clue for such a superinfection. Such CRP detection in serum during an acute phase of CNS infection is diagnostically important because a CRP increase suggests a purulent process
Scizures are usually of the grand mal type, but chorea, petit mal seizures, jacksonian epilepsy, and temporal lobe seizures may also occur, usually during the beginning of the acute stage. Organic syndromes are characterized by impairment of orientation and perception, loss of ability to calculate, memory loss, and psychosis. Our patient had general convulsions and signs of organic brain disease, both typical manifestations of lupus cerebritis; thus, we assumed that she had lupus cerebritis.
In a study involving 37 patients with neural lupus, Feinglass et al
detected CSF abnormalities in 32% of cases of neuropsychiatric illness. Demonstration of tachyzoites in tissue sections or smears of body fluids establishes the diagnosis of acute Toxoplasma infection.
in: Mandell GL Bennett JE Dolin R 4th ed. Mandeli, Douglas and Bennett's Principles and Practice of Infectious Diseases. Vol 2. Churchill Livingstone,
New York, NY1995: 2455-2475
in: Mandell GL Bennett JE Dolin R 4th ed. Mandeli, Douglas and Bennett's Principles and Practice of Infectious Diseases. Vol 2. Churchill Livingstone,
New York, NY1995: 2455-2475
The peroxidase-antiperoxidase technique with the use of antisera to Toxoplasma has proved to be both sensitive and specific in revealing the organism in the CNS.
Other methods for detecting Taxoplasma in body fluids or tissues include enzyme-linked immunosorbent assay, fluorescein-labeled monoclonal antibodies to Taxoplasma for touch preparations of specimens and rapid electron microscopy, polymerase chain reaction examination, and Wright-Giemsastained slides of sediment of CSF or smears of biopsy tissue.
In the immunocompromised host, taxoplasmosis is an important cause of morbidity and mortality.
Toxoplasma gondii infection of the central nervous system: use of the peroxidase-antiper-oxidase method to demonstrate toxoplasma in formalin fixed, paraffin embedded tissue sections.
Few reports of taxoplasmosis complicating SLE have been reported in the medical literature, and this emphasizes the difficulty in establishing the diagnosis. Noel and associates
found high titers of Taxoplasma antibodies to be more common in patients with SLE than in healthy control subjects, and therefore test results should be interpreted carefully.
described 4 cases of toxoplasmosis in patients with SLE. They also emphasized the diagnostic problems and recommended serologic analysis for taxoplasmosis before initiation of and during treatment with corticosteroids. Deleze et al
described taxoplasmosis of the brain that resembled lupus cerebritis and thus created a diagnostic challenge in a patient with SLE.
Conclusion
The diagnosis of CNS infection in SLE may be difficult. A patient with SLE and neurologic manifestations is naturally suspected to have lupus cerebritis, especially when the primary symptoms are typical for SLE: psychosis and general convulsions. Nonetheless, a CNS infection must always be considered. Because laboratory diagnosis of lupus cerebritis is difficult and computed tomography is frequently nonspecific, other methods such as lumbar puncture should be performed when CNS symptoms are present. Magnetic resonance imaging is the most sensitive radiographic technique to detect changes of SLE and may be helpful in diagnosing lupus cerebritis Both lumbar puncture and magnetic resonance imaging, however, may fail to identify CNS infection in a patient with SLE. Because the clinical manifestations of Taxoplasma infection may be protean and nonspecific, it must be carefully considered in the differential diagnosis of lupus cerebritis. Either histological diagnosis or serologic tests for demonstration of Taxoplasma antigen or specific antibody in both blood and CSF should be performed when lupus cerebritis does not abate with conventional immunosuppressive therapy.
References
Mok CC
Lau CS
Yuen KY
Cryptococcal meningitis presenting concurrently with systemic lupus erythematosus.
in: Mandell GL Bennett JE Dolin R 4th ed. Mandeli, Douglas and Bennett's Principles and Practice of Infectious Diseases. Vol 2. Churchill Livingstone,
New York, NY1995: 2455-2475
Toxoplasma gondii infection of the central nervous system: use of the peroxidase-antiper-oxidase method to demonstrate toxoplasma in formalin fixed, paraffin embedded tissue sections.
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