Sage Journals: Discover world-class research

Abstract

Central nervous system (CNS) tuberculosis (TB) is a rare but catastrophic event in patients with systemic lupus erythematosus (SLE). Here we report a case of cerebral TB in a patient with lupus myocarditis and nephritis, following cyclophosphamide immunosuppression. To our knowledge this is the first reported case of cerebral TB in SLE in a non-endemic country.

A 31-year-old female with SLE and a history of regular travel to Kenya presented to our centre with clinical features of acute heart failure. She was diagnosed with severe lupus myocarditis, and a renal biopsy also confirmed lupus nephritis. Prior to admission, she had also had a cough, fever and weight loss and was under investigation for suspected TB infection. She was treated with ivabradine, beta-blockers and diuretics together with methylprednisolone and cyclophosphamide immunosuppression. Subsequent sputum cultures confirmed TB and she was commenced on triple therapy. Despite this, she developed confusion, dizziness, blurred vision and fluctuating consciousness. Magnetic resonance imaging (MRI) and lumbar puncture revealed CNS TB infection resulting in meningitis. This was later complicated by obstructive hydrocephalus due to TB abscesses. A ventriculoperitoneal (VP) shunt was inserted and TB medications were given intravenously (IV) with dexamethasone. Following a prolonged hospital admission, the patient eventually recovered and rituximab treatment was used to control her SLE.

TB infection has been associated with SLE flares. It is likely in this case that TB exacerbated a lupus flare and subsequent immunosuppression resulted in mycobacterial dissemination to the CNS. Systemic and CNS features of TB and SLE are difficult to distinguish and their contemporaneous management represents a diagnostic and therapeutic challenge.

Keywords

TB SLE CNS infection cyclophosphamide brain

Get full access to this article

View all access options for this article.

References

WHO. Global tuberculosis report, Geneva: World Health Organization, 2016, pp. 1–179.

Mok

Chan

Wong

Lau

. Tuberculosis in systemic lupus erythematosus in an endemic area and the role of isoniazid prophylaxis during corticosteroid therapy. J Rheumatol 2005; 32: 609–615.

Sayarlioglu

Inanc

Kamali

et al.

Tuberculosis in Turkish patients with systemic lupus erythematosus: Increased frequency of extrapulmonary localization. Lupus 2004; 13: 274–278.

Tam

Wong

Szeto

. Risk factors and clinical features for tuberculosis among patients with systemic lupus erythematosus in Hong Kong. Scand J Rheumatol 2002; 31: 296–300.

Yun

Lee

Kim

et al.

The incidence and clinical characteristics of Mycobacterium tuberculosis infection among systemic lupus erythematosus and rheumatoid arthritis patients in Korea. Clin Exp Rheumatol 2002; 20: 127–132.

Zandman-Goddard

Shoenfeld

. Infections and SLE. Autoimmunity 2005; 38: 473–485.

Rock

Olin

Baker

Molitor

Peterson

. Central nervous system tuberculosis: Pathogenesis and clinical aspects. Clin Microbiol Rev 2008; 21: 243–261.

Sanna

Bertolaccini

Khamashta

. Neuropsychiatric involvement in systemic lupus erythematosus: Current therapeutic approach. Curr Pharm Des 2008; 14: 1261–1269.

Chu

Polesky

Bhatia

Bush

. Active and latent tuberculosis in patients with systemic lupus erythematosus living in the United States. J Clin Rheumatol 2009; 15: 226–229.

10.

Doria

Canova

Tonon

et al.

Infections as triggers and complications of systemic lupus erythematosus. Autoimmun Rev 2008; 8: 24–28.

11.

Lin

Liang

Liu

et al.

Tuberculosis as a risk factor for systemic lupus erythematosus: Results of a nationwide study in Taiwan. Rheumatol Int 2012; 32: 1669–1673.

12.

Appenzeller

Pineau

Clarke

. Acute lupus myocarditis: Clinical features and outcome. Lupus 2011; 20: 981–988.

13.

Busteed

Sparrow

Molloy

. Myocarditis as a prognostic indicator in systemic lupus erythematosus. Postgrad Med J 2004; 80: 366–367.

14.

Wijetunga

Rockson

. Myocarditis in systemic lupus erythematosus. Am J Med 2002; 113: 419–423.

15.

Hammann

Genton

Delabays

Bischoff Delaloye

Bogousslavsky

Spertini

. Myocarditis of mixed connective tissue disease: Favourable outcome after intravenous pulsed cyclophosphamide. Clin Rheumatol 1999; 18: 85–87.

16.

Brown

Clark

Smith

et al.

Variation in C-reactive protein response according to host and mycobacterial characteristics in active tuberculosis. BMC Infect Dis 2016; 16: 265–265.

17.

Bernaerts

Vanhoenacker

Parizel

et al.

Tuberculosis of the central nervous system: Overview of neuroradiological findings. Eur Radiol 2003; 13: 1876–1890.

18.

Jagetia

. Tuberculous vasculitis: The neurosurgeon's perspective. Neurol India 2016; 64: 868–870.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.10 MB

Cerebral tuberculosis in a patient with systemic lupus erythematosus following cyclophosphamide treatment: a case report

Abstract

Keywords

Get full access to this article

References

Supplementary Material