IT’S A STROKE, IT’S AN ABSCESS…NO, IT’S A TUMOR! OR IS IT?

Jessica Zuleta, MD*, University of Miami, Miami, FL;Aldo Pavon-Canseco, MD, University of Miami Miller School of Medicine, Miami, FL and John Ekladous, DO, Jackson Memorial Hospital, Miami, FL

Meeting: Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev.

Abstract number: 809

Categories: Adult, Clinical Vignette Abstracts

Case Presentation:  Central nervous system (CNS) systemic lupus erythematosus (SLE) is often called lupus cerebritis presenting primarily with non-specific symptoms of headaches, altered mental status, and/ or seizures. Up to 80% of SLE patients develop neurologic or psychiatric symptoms, the majority attributable to secondary causes.

64 yo female with SLE and class III/ IV nephritis s/p flare 1 month prior, remote provoked deep venous thrombosis (DVT), and hypertension presents to an outside hospital (OSH) with 1 day of left facial droop, slurred speech, and left arm weakness. Neurologic symptoms stabilized and she is transferred 7 days later to an academic medical center for further management of lupus nephritis and right basal ganglia (RBG) stroke.

On hospital day (HD) 1, neurology examination is notable for left side hemiparesis, intact consciousness and cognitive function (NIHSS score of 2). Admission radiologic studies are compared to those from OSH and suggestive of a stable RBG lesion. On HD 3, her neurologic status worsens; CT and MRI imaging show a non-hemorrhagic mass with new surrounding edema and mass effect on the right ventricle. Differential is broadened to include infection vs malignancy; brain SPECT-CT is suggestive of lymphoma.  She is maintained on mycophenolate, high dose steroids, and empiric broad spectrum antibiotics, antivirals, and antifungals. Attempts to obtain a brain biopsy are hindered by complications:  gastrointestinal bleeding with thrombocytopenia (platelets= 52, 000/ µL), renal failure requiring hemodialysis, and CMV reactivation viremia.

By HD 28, platelets rise to 142, 000/ µL and she undergoes a needle guided stereotactic brain biopsy of the RBG lesion.  Pathology shows demyelination; no evidence of malignancy, necrosis, or infection.  Immunosuppression therapy is adjusted to azathioprine and steroids. On HD 50, she is transitioned to a rehabilitation center with improved renal function, cell counts, mental status, and neurologic symptoms.

Discussion: Our patient’s clinical picture was caused by CNS demyelination, a primary manifestation of SLE. Neurologic and psychiatric symptoms that are primary manifestations of SLE fall under neuropsychiatric SLE (NPSLE).  Since presentations of NPSLE are varied, involving either the CNS or the peripheral nervous system (PNS), diagnosis is delayed.  Individuals with NPSLE have a 10x mortality increase compared to the general population.

Conclusions:  To our knowledge, this is a unique presentation of NPSLE manifesting with focal neurologic symptoms and radiologic studies suggesting stroke, CNS lymphoma or abscess.

To cite this abstract:

Zuleta, J; Pavon-Canseco, A; Ekladous, J . IT’S A STROKE, IT’S AN ABSCESS…NO, IT’S A TUMOR! OR IS IT?. Abstract published at Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev. Abstract 809. Journal of Hospital Medicine. 2017; 12 (suppl 2). https://www.shmabstracts.com/abstract/its-a-stroke-its-an-abscess-no-its-a-tumor-or-is-it/. Accessed September 19, 2019.

« Back to Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev.