| Clinical features |
- Acute mental status change may take the form of decreased level of consciousness, delirium or acute confusional state, or acute psychosis
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| Differential diagnosis – Causes include those that are SLE related and those that are not |
- SLE-related considerations:
- SLE CNS neuroinflammatory process (sometimes referred to as "lupus psychosis")
- Stroke (including APS, TTP)
- Seizure
- Systemic or CNS infection
- Medication toxicity (especially glucocorticoid toxicity)
- Hypertensive encephalopathy
- RPLS (PRES)
- Macrophage activation syndrome
- Electrolyte abnormalities, especially with renal disease
| - Non-SLE-related considerations:
- Metabolic derangements
- Drugs, medications, toxins
- Infection
- Trauma/exposure
- Stroke
- Seizure
- Primary psychiatric disorders
- Systemic organ failure
- Other
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| Evaluation |
- Comprehensive history and physical examination
- Laboratory studies:
- Electrolytes
- BUN/creatinine
- Liver function tests
- CBC with differential
- TSH
- Ammonia
- Urinalysis
- Toxicology as indicated
- Cultures as indicated
- Neuroimaging: Head CT urgently; in follow-up, MRI of the brain with and without gadolinium
- Lumbar puncture and CSF examination:
- Opening pressure
- Cell count with differential
- Total protein
- Glucose (with corresponding serum glucose for comparison)
- IgG index/oligoclonal bands (requires serum sample)
- Culture
- Additional infectious diagnostics as clinically indicated
- Neuronal autoantibodies as clinically indicated
- EEG
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| Diagnosis of SLE-associated neuroinflammatory process (lupus psychosis) |
- The attribution of an acute altered mental status to an SLE-associated neuroinflammatory process requires that other causes are excluded with the above evaluation.
- Evidence of concomitant SLE disease activity supports neuroinflammatory etiology.*
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| Management |
- Urgent treatment of infection, seizure, metabolic derangement, drug toxicity, stroke, etc, if present.
- For patients with high level of suspicion of lupus psychosis: Treat with pulse glucocorticoids and/or other immunosuppressive therapy.
- Antipsychotic drugs as needed for severe symptoms.
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