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A difficult case
Balancing immunosuppression and infection: recurrent enterovirus encephalitis in SLE
  1. Sanjay Cheema1,
  2. Eva Bunting2,
  3. Catriona Good3,
  4. Vijay Hajela4,
  5. Basil H Ridha1,
  6. Romi Anirban Saha1
  1. 1 Neurology, Brighton and Sussex University Hospitals NHS Trust, Haywards Heath, UK
  2. 2 Neurology, National Hospital for Neurology and Neurosurgery, London, UK
  3. 3 Neuroradiology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
  4. 4 Rheumatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
  1. Correspondence to Dr Sanjay Cheema, Neurology, Brighton and Sussex University Hospitals NHS Trust, Haywards Heath, Sussex RH16 4EX, UK; sanjay.cheema{at}nhs.net

Abstract

A young woman with systemic lupus erythematosus (SLE) developed recurrent enterovirus meningoencephalitis while taking prednisolone, azathioprine and rituximab. After reducing the immunosuppression, she developed a central nervous system (CNS) flare of SLE, with enterovirus still present in the cerebrospinal fluid (CSF). There are no evidence-based specific treatments for enterovirus encephalitis, but she responded well to intravenous immunoglobulin alongside pulsed methylprednisolone and rituximab. This case highlights the difficulties in managing people with co-existing infective and autoimmune conditions, especially if each affects the CNS. A viral infection and SLE flare can resemble one another clinically, although here the radiological differentiation of CNS lupus versus enterovirus encephalitis helped to guide the diagnosis.

  • neurovirology
  • SLE
  • encephalitis
  • infectious diseases

https://doi.org/10.1136/practneurol-2019-002229

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    Footnotes

    • Contributors All the authors were involved in the patient’s clinical care. SC and EB wrote the first draft and performed the literature review. All the authors were involved in editing the manuscript and approval of the final version submitted for publication.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent for publication Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed by Fady Joseph, Newport, UK.