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 Table of Contents  
LETTER TO EDITOR
Year : 2018  |  Volume : 13  |  Issue : 2  |  Page : 139-140

Aseptic meningitis as the first manifestation in a young male with systemic lupus erythematosus


1 Department of Internal Medicine, Iqraa International Hospital and Research Centre, Calicut, Kerala, India
2 Department of Neuropsychiatry, Iqraa International Hospital and Research Centre, Calicut, Kerala, India

Date of Web Publication24-May-2018

Correspondence Address:
Dr. N A Uvais
Department of Neuropsychiatry, Iqraa International Hospital and Research Centre, Calicut, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/injr.injr_143_17

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How to cite this article:
Moideen S, Uvais N A. Aseptic meningitis as the first manifestation in a young male with systemic lupus erythematosus. Indian J Rheumatol 2018;13:139-40

How to cite this URL:
Moideen S, Uvais N A. Aseptic meningitis as the first manifestation in a young male with systemic lupus erythematosus. Indian J Rheumatol [serial online] 2018 [cited 2019 Aug 18];13:139-40. Available from: http://www.indianjrheumatol.com/text.asp?2018/13/2/139/228279



Dear Editor,

Systemic lupus erythematosus (SLE) is a multisystem autoimmune inflammatory disorder with diverse clinical and immunological features, characterized serologically by autoantibodies targeting self-proteins, notably anti-nuclear antibodies (ANAs).[1] It is substantially more common in females of childbearing age with a female:male ratio of 8–15:1 probably relates to the effect of endogenous sex hormones, which have complex effects on the immune system.[2] Neuropsychiatric manifestation of SLE in the form of cerebrovascular disorders, seizures, or psychosis is well described in the literature.[3] However, aseptic meningitis as an initial presentation of SLE is rare, especially in male patients.[4] Here, we present a case of a young male with aseptic meningitis as an initial manifestation of SLE.

A 26-year-old male without significant past medical history was admitted with altered behavior for 2 days. The patient had fever, headache, vomiting, and cough with expectoration for the last 3 weeks. On examination, the patient was disoriented with mild fever and neck stiffness. Neurological examination showed no focal deficit. Computed tomography brain with contrast was normal except for an extra-axial cerebrospinal fluid (CSF) density lesion in the right temporal fossa, possibly arachnoid cyst. The laboratory studies showed mild leucopenia (3900/mm 3 [neutrophils: 82%]) and elevated erythrocyte sedimentation rate (37 mm/h). On CSF study, the opening pressure was 250 mmH2O, and CSF-pleocytosis (white blood cells 135/mm 3 [lymphocyte 95%]) with normal protein and glucose level were found. Blood and CSF tests for viral, tuberculous, fungal, and bacterial agents were all negative.

Through conservative management, his clinical symptoms partially improved but intermittent fever persisted. Prophylactic antibiotics were started initially but discontinued later due to the absence of evidence for bacterial agents in the blood and CSF.

One week after admission, the patient developed malar rash on his face with high fever. Leukopenia (2500/mm 3 [neutrophils: 71%]) was aggravated. He also developed vasculitic rash on upper extremities, along with severe pain all over the body. Autoimmune etiology was thought of at this stage and ANA was positive done by IFA.

Shortly afterwards ANA profile confirmed positive anti-SM and anti-ribonucleoprotein antibodies. Based on his clinical symptoms including malar rash, vasculitis, and hematologic manifestation including positive ANA, diagnosis of SLE was made. The patient was started on oral steroids on outpatient department basis and found to be maintaining improvement during follow-up after 1 week.

Aseptic meningitis as an initial presentation of SLE is extremely rare, especially in a male patient with SLE. A prospective study which evaluated major central nervous system (CNS) involvement in SLE found that only 4.3% of CNS affected patients presented with aseptic meningitis.[5] SLE-associated aseptic meningitis is thought to be part of vasculitic phenomenon or the effect of various drugs used in the treatment of SLE like nonsteroidal anti-inflammatory drugs.[4]

Studies on gender difference of SLE presentation have failed to prove that there is a particular type of lupus among males with older at disease onset, a more severe course in the form of increased incidence of renal disease, serositis, thromboses, and discoid skin disease.[2] However, the clinical phenotype at presentation has been shown to vary with gender. A lower incidence of musculoskeletal symptoms, RP, alopecia and photosensitivity, and more prevalent serositis and discoid lupus in men at diagnosis has been seen.[2]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lisnevskaia L, Murphy G, Isenberg D. Systemic lupus erythematosus. Lancet 2014;384:1878-88.  Back to cited text no. 1
[PUBMED]    
2.
Murphy G, Isenberg D. Effect of gender on clinical presentation in systemic lupus erythematosus. Rheumatology (Oxford) 2013;52:2108-15.  Back to cited text no. 2
[PUBMED]    
3.
Ainiala H, Loukkola J, Peltola J, Korpela M, Hietaharju A. The prevalence of neuropsychiatric syndromes in systemic lupus erythematosus. Neurology 2001;57:496-500.  Back to cited text no. 3
[PUBMED]    
4.
Kim H, Kim D, Koo Y, Oh S, Kim HS, Kim W, et al. A case of systemic lupus erythematosus presenting as aseptic meningitis. J Neurocrit Care 2008;1:62-4.  Back to cited text no. 4
    
5.
Kampylafka EI, Alexopoulos H, Kosmidis ML, Panagiotakos DB, Vlachoyiannopoulos PG, Dalakas MC, et al. Incidence and prevalence of major central nervous system involvement in systemic lupus erythematosus: A 3-year prospective study of 370 patients. PLoS One 2013;8:e55843.  Back to cited text no. 5
[PUBMED]    




 

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