Central Nervous System Tuberculosis Mimicking Neuropsychiatric Systemic Lupus Erythematosus To the Editor: W e read with interest the report in the Journal of Clinical Rheumatology that tuberculosis (TB) is not uncommon even in patients with systemic lupus ery- thematosus (SLE) being followed up in a county hospital in the United States. 1 We present a patient with SLE who developed an uncommon form of TB. This 42-year- old man presented with intermittent fe- ver, joint pains, weight loss (7 kg) since 9 months and oral ulcers and a rash on the face for the past 20 days. He had a malar rash, oral ulcers, and hepatomegaly of 3 cm below the costal margin. Investiga- tions revealed transaminitis, mild thrombo- cytopenia, positive result in the antinuclear antibody test, low complements, and ele- vated double-stranded DNA (Table 1 avail- able online). He was diagnosed with SLE with lupus hepatitis and started on pred- nisolone 1 mg/kg per day and azathioprine 2 mg/kg per day. At 6 months of follow- up, he was much better, and his pred- nisolone treatment had been tapered to a maintenance dose of 7.5 mg. One year after diagnosis, he pres- ented to the emergency services with fever lasting 6 weeks and altered sensorium for 3 days. There was no history of headache, vomiting, or seizures. He was agitated and was moving all his limbs. There was no neck rigidity or papilledema. Bilateral re- flexes were exaggerated, and plantars were up-going. Results from respiratory, car- diovascular, and abdominal examinations were normal. The differential included con- ditions related or unrelated to lupus. Un- related causes included infections like meningitis (partially treated bacterial, tu- bercular, or fungal), viral encephalitis, en- teric encephalopathy, cerebral malaria, and disseminated brain parenchymal infec- tions. Increased activity of SLE could also present with neuropsychiatric involvement and fever. Investigations revealed bicytopenia but normal electrolytes and blood glucose levels. Chest radiography revealed doubt- ful basal infiltrates. Result from the cere- brospinal fluid (CSF) examination was normal. Serum complement revealed a low level of C4 (see Table 1, SDC 1, http:// links.lww.com/RHU/A17). Considering the normal result from the CSF examination, the absence of focal deficits, bicytopenia, and the low C4, a possibility of neuro- psychiatric SLE seemed likely. However, imaging clinched the diagnosis. The mag- netic resonance image showed multiple ring-enhancing lesions in the cerebral hemispheres and brainstem (see Figure 1, SDC 2, http://links.lww.com/RHU/A18), and the high-resolution computed tomo- graphic scan of the chest showed mil- iary shadows (see Figure 2, SDC 3, http://links.lww.com/RHU/A19). A bone marrow biopsy showed ill-formed granu- lomas and necrosis of marrow tissue but was negative for acid-fast bacilli (not shown). AntiYtubercular therapy (AAT) was started, and prednisolone dosage was increased to 40 mg/d. The dosage of prednisolone was gradually tapered later. After 1 year of treatment, a second mag- netic resonance image showed resolution of most tuberculomas (see Figure 3, SDC 4, http://links.lww.com/RHU/A20). AntiY tubercular treatment was subsequently con- tinued for another year, after which a third magnetic resonance image showed com- plete clearance of tuberculomas (not shown). One year later, he remains well except for some forgetfulness. Since the recognition of an in- creased risk of TB in lupus in the 1980s, it has come to rank among the most common infections in lupus patients. 2 Important risk factors for TB in SLE in- clude a recent diagnosis of lupus (1Y2 y), active disease, and a high dose of steroids (cumulative or concurrent). 3Y9 The lungs remain the commonest site of involve- ment by TB in SLE (see Table 2, SDC 5, http://links.lww.com/RHU/A21). However, many studies have found a higher propor- tion of extrapulmonary and disseminated forms to occur in patients with lupus. 3Y5 Among these extrapulmonary sites, central nervous system TB (CNS TB) is not un- common and accounts for up to 10% of all cases of TB in SLE (see Table 2, SDC 5, http://links.lww.com/RHU/A21). Tubercular meningitis remains the commonest form of CNS involvement in SLE. Parenchymal tuberculomas or ‘‘small abscesses’’ like in our case are reported less frequently. 10 The presence of headache, vomiting, altered sensorium, or a focal deficit can be a clue to CNS TB. The CSF level is in- variably abnormal in meningitis; however, in tuberculomas, the CSF level may be normal (raised protein in 50%). Tubercu- lomas are recognized on magnetic reso- nance or computed tomographic scans as ring-enhancing lesions but cannot be re- liably differentiated from toxoplasmosis, neurocysticercosis, fungal infections, and metastatic neoplasia. 11 The presence of disseminated TB, specifically concomi- tant lung involvement, can be a clue to tubercular etiology as in our case. Cur- rent guidelines recommend 1 year of ATT; however, intracranial tuberculomas often take a long period to resolve. One study found two thirds of patients (without SLE) to have residual lesions after 1.5 years of ATT, necessitating prolonged therapy 11,12 Steroids have a definite role in tubercular meningitis and a possible role in intracra- nial tuberculomas; the recommended dos- age varies from 12 mg/d dexamethasone to 4 mg/kg per day prednisolone for 4 weeks. 11 In the setting of SLE, CNS TB can be fatal in a matter of days, so early treatment is recommended. 10 Varun Dhir, MD, DM Yogesh Preet Singh, MD, DM Ramnath Misra, MD, FRCP Amita Aggarwal, MD, DM Department of Immunology Sanjay Gandhi Post Graduate Institute of Medical Sciences Lucknow, India aa.amita@gmail.com REFERENCES 1. Chu AD, Polesky AH, Bhatia G, et al. Active and latent tuberculosis in patients with systemic lupus erythematosus living in the United States. J Clin Rheumatol. 2009;15: 226Y229. 2. Alarcon GS. Infections in systemic connective tissue diseases: systemic lupus erythematosus, scleroderma and polymyositis/dermatomyositis. Infect Dis Clin North Am. 2006;20:849Y875. 3. Hernandez-Cruz B, Sifuentes Osornio J, Ponce de Leon Rosales S, et al. Mycobacterium tuberculosis infection in patients with systemic rheumatic diseases. A case-series. Clin Exp Rheumatol. 1999;17:289Y296. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jclinrheum.com). LETTER TO THE EDITOR 114 www.jclinrheum.com JCR: Journal of Clinical Rheumatology & Volume 18, Number 2, March 2012 Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.