SLE and CNS Lesions


Cherie O'Brien, M.D.

44 yo lady comes from out of state and lands in Texas in Feb.  Walks into her family practitioner's office and was living independently.  By the end of Feb is checked into a nursing home.  Now she thinks it's April as we Texans embrace our 104 degrees.  I meet her for the first time after she has been at 2 other major centers.  I'm asked why she is demented, why does she hurts ALL over, why does she have choreiform movements, why can she no longer walk, why is she leukopenic, why she has shoddy lymphadenopathy.  ...So I ask myself why me?

I then get an MRI of her brain and I ask myself why I had to go and do that. I asked 5 of our neuroradiologists (I am pampered I know) why she has bright areas in her internal capsules that extend up into the subcortical white matter AND down into her brainstem via the corticospinal tracts. 

I got several answers. 

Answer number one always bothers me because it means they haven't much seen this before: Vasculitis. 

Answer number two was reasonable but she had not been on anything stronger than brief Imuran/Azathioprine and ? duration of Cytoxan/cyclophosphamide: Toxic Leukoencephalopathy. Since the only other drug I could think to get rid of was Plaquenil I did so with Rheum's blessing. I asked why a spot in her left caudate area was enhancing and they said that was a good question, but it had enhanced back in April at Mecca Center #2. Therefore, it was not a small stroke like what Mecca #2 reported. 

Answer number 3 is she has symmetric hyperintense signals of unknown etiology. I then did a medline search and found out that in spite of the teaching that patchy subcortical areas of hyperintense signals are SLE, one can see these symmetric signals as a form of SLE of the brain. I have asked Rheum to come back and see about putting her on steroids. 

I have also asked for images so I can show you. Since PML can look like SLE of the brain I am treading carefully. Any of you seen this type of case before?

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Revised 8/20/2000

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